RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04188
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20031218 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Food Service) medically separated for “chronic low back pain secondary to myofascial pain.” rated at 10%.  

CI CONTENTION:  The CI requests the Board consider all conditions.  His 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 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 confined to 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:  

Admin Correction – Dated 20031031	VA* - (~1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain Secondary to Myofascial Pain…	5237	10%	Lumbar Spine Myofascial Pain Syndrome and Chronic Thoracic Spine Strain	5237-5025	20%	20031114	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7 	
RATING:  10%	COMBINED RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20041007 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Low Back Pain Secondary to Myofascial Pain.  The record shows that the CI was first seen for low back pain (LBP) in 1988 after lifting a canvas cover for a 2½ ton truck.  Over the next decade, he was evaluated periodically for LBP, but was able to continue his duties.  On 6 October 2000, the CI reported LBP since he had been a passenger in a motor vehicle accident (MVA) a month earlier.  He was treated with medications, duty restrictions, and physical therapy (PT), but his pain persisted.  Lumbar spine X-rays on 28 June 2001 were normal as was magnetic resonance imaging (MRI) on 2 April 2002.  A bone scan on 25 April 2002 showed no spinal abnormalities.  A physical medicine note dated 15 January 2003, 11 months prior to separation, documented that the CI had been a passenger in a taxi, which was in a MVA in September 2000.  The CI was able to make several long drives and did not seek medical attention for a month.  On examination, he had a taut band in the lumbar paraspinal muscles, but full range-of-motion (ROM), a normal gait, and normal neurological examination.  Follow-up examinations also showed a normal ROM.  Electrodiagnostic studies on 27 February 2003 were normal.  A neurosurgical examination on 13 May 2003 was normal.  The narrative summary (NARSUM) was dated 11 June 2003, 6 months prior to separation.  The CI was noted to have full ROM with normal motor and sensory function.  Taut bands and tenderness were noted over the lumbar paraspinal muscles.  At the VA Compensation and Pension (C&P) examination performed on 14 November 2003, a month before separation, the CI reported that he had been incapacitated for over a month the prior year from his LBP.  This is not supported by the records in evidence.  He reported daily flares in pain upon wakening which reduced his ROM by 50%.  He was tender to palpation over the thoracic spine, but his posture was normal.  The gait was not recorded.  The ROM was full as recorded below and did not decrease with repetition.  Painful motion was not recorded.  He was noted to have normal strength and reflexes.  The examiner recorded that “The estimated decreased range of motion in back with severe flares cannot is estimated at 50%.  This cannot be assessed at this time because he is not having a flare [sic].”  He was diagnosed with lumbar spine myofascial pain syndrome.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	MEB ~6 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (90 Normal)	Full Normal ROM without pain	90 (95)	
Combined (240)		240	
Comment	TTP noted	No decrease with repetition; tender to palpation	
§4.71a Rating	10%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 10%, coded 5237 (lumbar strain).  The VA rated the back at 20%, coded 5237-5025 (lumbar strain and fibromyalgia), stating that the examiner had recorded that the ROM decreased 50% in a severe flare.  The Board noted that the examiner actually stated that this could not be assessed.  The Board also observed that fibromyalgia was not diagnosed until 10 years after separation and that the CI did not meet the criteria for the diagnosis at separation.  The tenderness to palpation found on both the MEB and VA examinations supports a 10% rating.  The Board found no route to a higher rating.  The evidence does not support the presence of an unfitting radiculopathy at separation.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic LBP condition.  

BOARD FINDINGS:  In the matter of the chronic LBP condition and IAW VASRD §4.71a, 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 20140926, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160004464 (PD201404188)

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
( ) OVA