RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00027
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081017

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Fire Direction Specialist, medically separated for “thoracic back pain,” with a disability rating of 20%.

CI CONTENTION:  “Chronic Back Pain, Degenerative Disc Disease, Compressed Disc in T8-T9, About to get back surgery through the VA to correct Compressed Disc, disability through the Army did not include PTSD which I am rated at 50% through the VA and was treated for by Army Doctors from around October of 2007 until my medical discharge in October of 2008.”  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 - 20080626	VARD - 20090213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracic Back Pain	5299-5237	20%	Low Back Strain with DJD	5242	10%	20090107	
Anxiety Disorder NOS	Not Unfitting	PTSD	9411	10%	STR	
Non-Radicular Lumbar Spine Endplate Degeneration	Not Unfitting	No VA Entry	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Thoracic Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s thoracic back pain condition began in September 2005 during the first month of basic training.  He recovered fully and was deployed in August 2006 to October 2007.  During deployment he functioned as a gunner and developed back pain with muscle spasms.  He subsequently fell off a Humvee and further aggravated his back pain.  Thoracic X-rays were normal.  Thoracic magnetic resonance imaging (MRI) showed disc protrusions at multiple mid-thoracic disc levels, with mild spinal canal narrowing.  Lumbar MRI showed mild spinal arthritis.  At a physical medicine evaluation on 28 April 2008, the CI reported mid-back pain graded 4/10.  He was taking a muscle relaxant, which helped.  The examiner noted there was radiation of the pain to the thighs, but no further, and no neurological symptoms or motor or sensory disturbances.  The CI reported occasional great toe numbness that the PM specialist noted was unrelated to the back.  The examination showed a normal gait.  There was thoracic tenderness and muscle spasm with an abnormal appearance of the spine.  Thoracolumbar flexion was 80 degrees (normal 90 degrees) and combined ROM of 205 degrees (normal 240 degrees) with painful motion.  Lower extremity strength, sensation, and reflexes were normal.  Straight leg testing to elicit radicular symptoms was negative.  Despite treatment the CI continued to have mid-back pain.  The MEB forwarded “Nonradicular Thoracic Spine Intervertebral Disc Protrusions” and “Nonradicular Lumbar Spine Endplate Degeneration” for PEB adjudication.  

At the MEB examination dated April 2008, 6 months prior to separation, the CI reported chronic back pain aggravated by activities, with flare-ups due to muscle spasm, with numbness radiating to both feet.  Physical examination showed a normal gait.  There was no neurological deficit, muscle atrophy, or voluntary guarding.  There was tenderness of the thoracic and lumbar spines with “minimal” thoracic muscle spasms.  Lower extremity strength, sensation, and reflexes were normal and pulses were intact.  The CI was able to toe and heel walk without difficulty.  Thoracolumbar flexion was 72 degrees after three repetitions and combined ROM was 184 degrees (normal 240 degrees).

At the 7 January 2009 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported chronic back pain, that radiated to the thighs, but not the lower legs.  The BP was aggravated by activities, including driving and walking for 20 minutes.  He was taking medication and limiting his activities.  He was not using an assistive device for ambulation and did not wear a brace.  Physical examination showed a normal gait.  There was no tenderness to palpation (TTP) of the spine.  The right leg was 1 inch shorter than the left resulting in a pelvic tilt.  The CI could flex forward and reach the tibia with his hands.  Forward flexion was measured at 65 degrees and combined ROM was 180 degrees, with painful motion.  There was muscle spasm in the back with normal spinal alignment.  There was “mild” lumbar spine TTP.  Lower extremity strength, sensation, and reflexes were normal and SLR was negative.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the thoracic back condition 20%, coded 5299-5237 (analogous to lumbosacral strain), citing a 10% rating based on objective examination findings at the MEB examination, raised to 20% based on additional functional loss as reported by the CI, IAW VARSD §4.10 (Functional impairment), §4.40 (Functional loss), and §4.59 (Painful motion).  The VA rated the back condition 10% coded 5242 (degenerative spinal arthritis), based on the VA C&P examination 3 months after separation, citing limitation of motion.  
  
The PEB assigned a 20% rating, under the 5237 code and the Board may not recommend a combined rating lower than that of the PEB IAW DoDI 6040.44.  Therefore, the Board reviewed to see if there was a path to a higher rating.  There was no evidence of thoracolumbar forward flexion limited to less than 30 degrees.  There was no ankyloses of the TL spine.  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  The Board concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB.  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 thoracic back condition.  

Contended PEB Conditions:  Anxiety Disorder NOS and Non-Radicular Lumbar Spine End Plate Degeneration.   The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  Additionally, as noted above in the analysis summary, the lumbar spine condition cannot be separated from the thoracic back pain condition for separate rating IAW VASRD rating guidelines.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determinations for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the thoracic back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder, NOS and non-radicular lumbar spine end plate degeneration conditions, the Board unanimously recommends no change from the PEB determinations 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 , 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, AR20160018784 (PD201500027)

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