RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04246
BRANCH OF SERVICE: Army	SEPARATION DATE:  20080715

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E8, Mechanical Maintenance Supervisor, medically separated for “lumbosacral strain,” with a disability rating of 10%.  

CI CONTENTION:  The CI submitted a three page letter requesting review of all his conditions.  The applicant’s complete submission, with attachments, 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 - 20080616	VARD - 20070806	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Chronic Low Back Strain	5237	20%	20060914	
Hypertension	Not Unfitting	Hypertension	7101	10%	20060914	
Ventral Hernia		Residuals , Repair of Epigastric Hernia	7339	NSC	20061011	
OSA		No VA Placement	
Flat Foot		No VA Placement	
Obesity		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began on 8 November after pulling a very heavy soldier from a HUMVEE during training (a VA note indicated when deployed) at which time he felt a “pop” in his back that was treated with Neurontin (gabapentin for nerve pain) and Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)).  In November 2005 the CI reported low back pain for a year and noted when he sat for a long time, his legs went “dead.”  

At the VA Compensation and Pension (C&P) examination on 14 September 2006, performed 22 months prior to separation, the CI reported constant sharp pain with a severity of 8/10 (10 being the worst pain) in his right and left low back with radiation down the legs on an intermittent basis and daily numbness over the left side of his lower leg.  On examination his posture was normal as was his gait, which was narrow based.  He was able to rise onto his toes and heels, tandem walk and rise from a squat without much difficulty, but he did grimace in pain.  He wore an abdominal brace post-surgery (see below).  Range of motion (ROM) measurements are noted in the chart below.  Pain began at 45 degrees flexion and was present at all end of motion movements although the CI reported flexion was limited to 45 degrees during a flare.  There was diffuse tenderness to palpation over the left paraspinal muscles.  Straight leg testing (to determine nerve root irritation) was positive on the right and there was decreased sensation to monofilament testing in the left lower extremity.  Strength was 5/5 in the lower extremities.

An MRI in February 2007 demonstrated some bulges and neural foraminal stenosis (narrowing where the nerves pass through spaces between adjacent vertebrae).  An orthopedic note on 5 March 2008 indicated that despite physical therapy, home exercises, and medication (Flexeril, a muscle relaxer) and Vicodin (a narcotic and pain reliever combination), the CI had to give up two sports, had a PL2 profile for sit-ups, and could not walk fast without having back throbbing pain.  He had a pain level of 8/10 (10 being the worst pain), which worsened with activity.  He reported use of a bed with heat and massage capabilities provided some relief.

At a VA examination on 21 December 2007, 7 months prior to separation, the CI stated he experienced constant sharp pain with a severity of 6/10 in the low back and the pain radiated down his legs on a daily basis.  Additionally, he reported approximately 20 incapacitating episodes over the prior 12 months that lasted 2-3 hours and he was recommended to take medication and rest.  The ROM measurements are in the chart below with flexion of 70 degrees and extension to 30 degrees.  During a flare up flexion was limited to 0-45 degrees and extension to 0-20 degrees due to pain.  Straight leg raising was positive on the left and strength was 5/5 in the lower extremities with sensation to light touch that was intact in the lower extremities.

The NARSUM physical examination dated 5 March 2008, 4 months prior to separation, revealed a powerful man in no acute distress, who walked, sat, and stood slowly with some groaning.  His legs and back appeared normal without any tenderness to palpation; however, there was repeated lumbar paravertebral spasm with motion.  Straight leg raising (to determine nerve root irritation) was 48 degrees on the left and right in seated and supine positions.  ROM measurements are in the chart below and were limited by pain on each repetition.  Lumbar lordosis was increased and the neurological evaluation was unremarkable.  Heel and toe gait hurt his feet.  The examiner noted X-rays of the lumbosacral spine demonstrated mild degenerative joint disease with anterior spurring at several levels.  At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) in April 2008, 3 months prior to separation, the CI reported standing too long hurt his back.  The examiner noted lumbar spine pain with ROM movements and decreased forward flexion.  An MRI in February 2009 demonstrated minimal degenerative joint disease with no herniated nucleus pulposus or stenosis.  

The 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.  

Thoracolumbar ROM
(Degrees)	VA C&P ~22 Mo. Pre-Sep
	VA examination ~7 Mo. Pre-Sep
	MEB ~4 Mo. Pre-Sep
	
Flexion (90 Normal)	90 (with flare 45)	70 (with flare 45)	(65)77/70*/63*	
Extension (30)	30	30 (with flare 20)	(10)5/4*/12*	
R Lat Flexion (30)	30	30 (with flare 20)	(25)25/30/25	
L Lat Flexion (30)	30	20 (with flare 20)	(25)20/25/25	
R Rotation (30)	30	30 (with flare 20)	(30)37/37/37	
L Rotation (30)	30	30 (with flare 20)	(30)37/32/36	
Combined (240)	240	240	185	
Comment	Painful motion	Sensation of pulling and tightness; no loss with repetition	*Painful spasm	
§4.71a Rating	10% (with flare 20%)	10% (with flare 20%)	10% 	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (lumbosacral strain), citing lumbosacral strain.  The VA assigned a 20% rating using the 5237 code based on the VA C&P examination 22 months before separation, citing estimated flare limitation of motion.  Board members discussed the disparity between the VA examination where the estimated loss of motion due to a flare was provided and the MEB examination where it was not.  Of interest is that on repetition at the VA examination, there was no loss of motion.  Board members discussed the probative value of the MEB examination versus the VA examination.  The MEB examination was more proximate to separation; however, ROM measurements for both were similar, except for the estimated flare up decrements, which were subjective reports and not based on objective observations and/or measurements.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) reported on the MEB and VA examinations proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest, albeit the CI reported approximately 20 incapacitating episodes that lasted 2-3 hours each, which were recommended to be treated with medication and rest.  Therefore, a rating under the alternate VASRD formula (for IVDS) could not be achieved.  The Board also considered whether an additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  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.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  Therefore, the Board concluded that an additional disability rating was not justified on this basis.  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 lumbosacral condition.  
	
Contended PEB Conditions:  Hypertension, Hernia, Obstructive Sleep Apnea (OSA), Flat Feet, and Obesity.  The Board’s main charge is to assess the fairness of the PEB’s determination that hypertension, hernia, OSA, and flat feet were not unfitting.  The hypertension, hernia, OSA, and flat feet conditions were not profiled or explicitly implicated in the commander’s performance and functional statement, although it was noted the CI could not lift all required equipment for his MOS and he took a lot of rest periods to maintain the 8-10 hour work day.  In a memorandum for the commander dated 15 March 2008, abdominal surgery and sleep apnea were explicitly mentioned relating to the CI’s inability to reasonably perform his duties as a mechanic maintenance NCO.  Despite this the conditions were not judged to fail retention standards.  

Hypertension.  Blood pressure (BP) was 122/92 in November 2005 and according to VA records it was 136/92 in December 2005 with rechecks of 140/90 and 136/90.  The CI was started on antihypertensive medication (hydrochlorothiazide) immediately following his discharge from military service and had no symptoms or illnesses related to the hypertension although he reported chest pressure with heavy exertion, but did not take nitroglycerin. Blood pressure in October 2006 was 115/64.  A prescription for a combination medication consisting of hydrochlorothiazide and lisinopril for treatment of hypertension was filled in February 2008.  At the MEB examination on 3 April 2008 the CI’s BP was 118/75.

Hernia.  The CI reported epigastric diastasis (separation) of the rectus abdominis muscles marked by a bulge in the center of the abdomen when he performed a crunch maneuver while in service, which was noted on his exit examination from active duty.  He underwent surgical repair of the ventral diastasis of the rectus abdominis muscles on 20 August 2006.  Staples were removed on 5 September 2006 at which time the incision was well healed and continued to be well healed in October 2006.  

Obstructive Sleep Apnea (OSA).  The CI underwent polysomnography on 23 May 2007 for a history of fatigue, excessive daytime sleepiness, falling asleep unintentionally, having witnessed breathing pauses.  He was diagnosed with obstructive sleep apnea.  The CI reported at a VA examination dated 21 December 2007 that he had been using a CPAP machine since 5 June 2007, which he found very helpful and no longer had daytime hypersomnolence. 

Flat Feet.  The CI noticed pain in his feet on walking and standing after 15 minutes for 2 years and his feet hurt more when he tried to run.  X-rays on 21 February 2007 revealed normal feet with very minimal pes planus.  Larger boots, orthotic arch supports, and an injection of cortisone to neuroma of the foot help to improve the pain in his feet. 

Obesity.  At the time of the NARSUM examination in March 2008 the CI was reported to weigh 210 pounds and stood 63 inches tall, while at the MEB examination in April 2008 the CI was reported to weigh 219 pounds and stand 64 inches tall.  The Board noted that obesity is not a physical disability.

There was no performance-based evidence from the record that the 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 contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the lumbosacral strain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypertension, hernia, OSA, flat feet, and obesity conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20141106, 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 
XXXXXXXXXXXXXXXXXX, AR20160018305 (PD201404246)

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