RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04129
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090627

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Chaplain Assistant, medically separated for “degenerative arthritis of the lumbar spine…” with a disability rating of 20%. 

CI CONTENTION:  The CI requested consideration of all conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20090430	VARD - 20100126	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis Of The Lumbar Spine	5242	20%	Degenerative Arthritis Of The Lumbar Spine	5242	40%	20090924	
Lumbar Hyperlordosis	Not Unfitting					
Carpal Tunnel Syndrome	Not Unfitting 	Left Carp Al Tunnel Syndrome	8615	10%	20090924	
Left Leg
Compartment Syndrome	Not Unfitting	Left Lower Extremity Compartment Syndrome	5399-5311	0%	20090924	
Obesity	Not Constituting a Physical Disability	No VA Placement	
Varicosities	Not Unfitting	Bilateral Thigh Varicose Veins	7120	0%	20090924	
Pes Plantus [sic]	Not Unfitting	Bilateral Pes Planus	5276	10%	20090924	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Degenerative Arthritis of the Lumbar Spine.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lumbar spine condition began in October 2007 during a drill in Basic Training after practicing “fireman’s carry” with other soldiers.  The CI reported low back pain (LBP) radiating to the left lower extremity (LLE), with occasional numbness and tingling of the LLE.  At a primary care visit on 27 May 2008 there was tenderness and painful, but full range of motion (ROM) noted, with an otherwise unremarkable examination.  A lumbar MRI showed degenerative disc disease (DDD) and spinal arthritis which caused bilateral neuroforaminal narrowing at the L4-S1 levels.  At an initial chiropractic evaluation in July 2008, ROM was flexion of 45 degrees (normal 90 degrees).  Electrodiagnostic studies of the LLE in July 2008 were normal without evidence of lumbar radiculopathy.  At a neurosurgical consultation in July 2008 the examination noted the CI could sit and rise from a sitting position without difficulty and lower extremity strength, sensation, and reflexes were normal.  The neurosurgeon diagnosed DDD and recommended epidural steroid injections and continued conservative treatment.  The CI participated in physical therapy, chiropractic treatment, and had epidural steroid injections with temporary improvement at times.  A second neurosurgical opinion provided a letter to the record dated 12 February 2009 and indicated that he had recommended surgical fusion at L4-S1 for LBP with LLE pain, which the CI had postponed.  The CI wished to separate from the military first and reconsider the surgery after separation.  The MEB forwarded “low back pain” for PEB adjudication.

The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

DOS 20090627
Thoracolumbar ROM
(Degrees)	MEB ~4 Mo. Pre-Sep
(20090303) p.110	VA C&P ~3 Mo. Post-Sep
(20090924) p.120	
Flexion (90 Normal)	55 60 57 (57)	30*	
Extension (30)	8 6 8  (7)	15	
R Lat Flexion (30)	15 11 10 (12)	15	
L Lat Flexion (30)	12 10 9 (10)	15	
R Rotation (30)	25 28 27 (27)	15	
L Rotation (30)	26 24 22 (24)	15	
Combined (240)	137	105	
Comment	AO	*ROM after repetition	
§4.71a Rating	20%	40%	

At the MEB NARSUM examination on 3 March 2009, the CI reported constant LBP, pain level of 8/10, radiating down the LLE to the toes, with numbness in the same area.  He reported use of opioid pain medication as needed.  He did not take prescribed anti-inflammatory and muscle relaxant medications due to gastrointestinal side effects.  The physical examination noted a “slow but even” gait.  The CI was able to sit and move comfortably throughout the examination.  There was no tenderness or muscle spasm of the lumbar spine.  Increased lordosis of the lumbar spine was noted, which the examiner indicated was due to body habitus.  Strength, sensation, and reflexes of the lower extremities were normal and straight leg raise testing (SLR) was negative.  The CI was able to heel and toe walk.  Thoracolumbar ROM was as recorded in the chart above.  There was painful motion noted.  

At the VA Compensation and Pension (C&P) examination on 24 September 2009, 3 months after separation, the CI reported constant LBP with stiffness, fatigue and numbness and denied muscle spasm or bowel or bladder problems.  He reported that activity increased the pain, but he could function with medication.  He reported increased functional impairment with flare-ups due to pain, weakness, fatigue and decreased ROM.  The CI also reported “mild” LLE pain, once per month for one hour exacerbated by activity.  He could function without medication for the LLE pain and flare-ups did not result in any additional impairment due to LLE pain.  There was no surgical indication.  He reported the condition did not result in any incapacitation and he did not experience any overall functional impairment due to the low back condition.  Physical examination showed a normal gait.  There was normal spinal curves and no muscle spasm.  There was tenderness to palpation and radiating pain with bending.  There was no weakness or muscle atrophy noted and SLR was positive bilaterally.  Thoracolumbar ROM was as noted in the chart above.  There was additional limitation of motion with repetition due to pain and fatigue, with fatigue having the major functional impact.  Strength, sensation, and reflexes of the LEs were normal.  The VA examiner indicated that there were no signs of lumbar IVDS with chronic and permanent nerve root involvement.  Lumbar spine X-rays showed degenerative arthritis.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5242 code (degenerative arthritis of the spine), citing limitation of motion.  The VA assigned a 40% rating also coded 5242, based on the VA C&P examination 3 months after separation, citing limitation of motion (forward flexion) after repetition.  The Board noted that the MEB NARSUM and the C&P examinations reflected different TL ROM and deliberated the discrepancy.  The Board placed greater probative value on the MEB NARSUM examination in this case because treatment notes in the STR also reflected this degree of impairment based on limitation of motion.  Additionally, other findings of the C&P examination were improved from the MEB NARSUM.  The CI reported more localized LBP and less LLE pain and there was no muscle spasm noted at either examination, and therefore, there was no medical explanation apparent to the Board to account for the significant decreased ROM noted at the C&P examination.  According to VASRD §4.7 (higher of two evaluations), “when there is a question as to which of two evaluations will be applied”, whichever criteria more nearly approximate the disability picture “will be assigned.”  The Board agreed that the overall disability picture in this case was more nearly approximated by the 20% rating than the 40% rating.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported radiating pain and numbness of the LLE at the MEB NARSUM examination; however, the EMG/NCV studies of the LLE did not show evidence of a lumbar radiculopathy.  Lower extremity strength, sensation, and reflexes were normal at both the MEB NARSUM and C&P examinations.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  Radiating pain is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates)” and there was no evidence in this case that a motor or sensory deficit existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an additional disability rating was not justified on this basis.  

Contended PEB Conditions: Carpal Tunnel Syndrome (CTS), Lumbar Hyperlordosis, Left Leg Compartment Syndrome (CS), Varicosities, Pes Planus (PP), Obesity.  The Board’s main charge is to assess the fairness of the PEB’s determination that the CTS, lumbar hyperlordosis, left leg CS, varicosities, and PP conditions were not unfitting.  The CTS, lumbar hyperlordosis, varicosities, and PP conditions were not permanently profiled.  The CI was placed on a permanent L2 profile for the left leg CS, diagnosed after the CI was in the MEB process for the low back condition.  A “2” profile indicates a condition which requires some physical limitations, but is not in all cases disqualifying for continued military service.  None of these conditions were implicated in the commander’s statement or judged to fail retention standards.  Additionally, the PEB determined that obesity was a “condition not constituting a physical disability IA DoDI 1332.38, enclosure 5.  The Board has no basis to recommend the obesity condition as unfitting.  All conditions were reviewed and considered by the Board.  There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the degenerative arthritis of the lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended carpal tunnel syndrome, lumbar hyperlordosis, left leg compartment syndrome, varicosities, pes planus conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  In the matter of the obesity condition, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
AR20160018250 (PD201404129)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA