RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00093
BRANCH OF SERVICE:  Army                                                                 SEPARATION DATE:  20061217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Shower, Laundry and Clothing Repair Specialist, medically separated for “chronic back pain…” with a disability rating of 10%.

CI CONTENTION:  The applicant contends her back and a right and left knee condition.  She also contends bilateral hip and bilateral shin 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.  

In addition, the Secretary of Defense Mental Health Review Terms of Reference directed a comprehensive review of Service members with certain mental health (MH) conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The MH condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.

RATING COMPARISON:  

SERVICE PEB - 20061114	VARD - 20070731	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain...	5259-5237	10%	Lumbar Spondylosis	5239	10%	20070326	
Patello-Femoral Syndrome	Not Unfitting	Right Knee Patellofemoral Syndrome	5260	10%	20070326	
		Left Knee Patellofemoral Syndrome	5260	10%	20070326	
No Service Placement	Anxiety Disorder	9413	NSC	20070313	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic back pain condition began about October 2002 during basic training in the absence of trauma.  X-rays revealed no evidence of scoliosis and the CI was treated with physical therapy on multiple occasions, along with nonsteroidal anti-inflammatory drugs (NSAIDs), a muscle relaxer, and temporary profiles.   Magnetic resonance imaging (MRI) in May 2005 showed no evidence of significant degenerative disc disease, but there was very minimal baseline canal stenosis due to congenital short pedicles, which did not appear to cause any kind of nerve root impingement.  In September 2005 the CI noted the lower back pain radiated to her legs, which she was treated with cold packs, exercises, and medication.  In January 2006 the CI stated she occasionally had pain radiating into her right lower extremity with occasional paresthesias.  She had a normal gait, some decreased ROM and tenderness on palpation of the left and right paraspinal regions.  An MRI in February 2006 demonstrated disc bulging at L4-5, which combined with marked ligamentous and facet hypertrophy resulted in some minimal triangulation of the central canal and mild disc bulging at L5-S1.  Orthopedic evaluation in April 2006 revealed a normal range of motion (ROM) of the thoracolumbar spine with an unremarkable neurologic examination.  Celecoxib, an NSAID, was prescribed.  Pain worsened after wearing standard gear in May 2006 and the CI had tenderness to palpation in the L5 area.  Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever) was added to the treatment regimen.  Electro-diagnostic studies performed because the CI reported pain in the right leg were normal and without evidence of radiculopathy in June 2006.  A lumbar spine series on 11 August 2006 revealed no spondylolisthesis (one vertebra slides forward over the vertebra below it) and was otherwise unremarkable.  An MRI ordered because of worsening lower back pain in August 2006 revealed no interval change was apparent when compared to a previous study in February 2006.  

Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “lumbar spondylosis” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated August 2006, 4 months prior to separation, the CI reported pain in the upper part of her back when she sat in a forward position.  Physical examination revealed the CI had a full ROM, was mildly tender to palpation in the midline around the L3 level, and had mild swelling of the paraspinous muscles in the L3-L5 areas.  The NARSUM dated 25 August 2006 noted the CI’s gait was normal and her neurologic evaluation was unremarkable and there was a full ROM of the extremities, which were nontender to palpation.
At the VA Compensation and Pension (C&P) examination on 26 March 2007, performed 3 months after separation, the CI reported chronic daily back pain at a level of 6/10 (10 being the worst pain) and up to 10/10 with flares, which occurred with prolonged standing, sitting more than 2 hours, or repeated bending; however, she could walk up to 6 miles.  Pain radiated down her right or left leg with residual tingling of the foot.  Physical examination revealed a normal gait with mild paraspinal muscle tenderness.  ROM measurements are in the chart below.    

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)	PT/MEB ~6 Mo. Pre-Sep
	VA C&P ~3 Mo. Post-Sep
	
Flexion (90 Normal)	105(90)	90	
Extension (30)	25	30	
R Lat Flexion (30)	40(30)	30	
L Lat Flexion (30)	30	30	
R Rotation (30)	25	30	
L Rotation (30)	70(30)	30	
Combined (240)	230	240	
Comment	Pain on flexion, extension, and right rotation	Painful motion on extension; mild paraspinal tenderness.	
§4.71a Rating	PEB 10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5299-5237 code (lumbosacral strain), citing chronic back pain, without neurologic or electrodiagnostic abnormality and a combined thoracolumbar ROM greater than 240 degrees, with localized tenderness.  The VA also assigned a 10% rating using the 5239 code (spondylolisthesis or segmental instability) based on the VA C&P examination 3 months after separation, citing muscle spasm on examination.  Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of painful motion.  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 documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  The Board also considered whether an additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported intermittent paresthesia/numbness to the legs; however the electrodiagnostic studies showed no evidence of neuropathy or radiculopathy.  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 sensory deficit or motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness or a sensory deficit existed to any degree that could be described as functionally impairing.  Thus, 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 chronic back pain condition.  

Contended PEB Condition: Patellofemoral Syndrome.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

Anxiety.  The MEB did not address the condition nor did the PEB adjudicate the condition.  It was not profiled or implicated in the commander’s statement.  Notes on 8 November 2002, 18 November 2002, and 10 December 2002 indicated the CI was seen for a “panic disorder,” “anxiety attack,” or “panic attack” marked by hyperventilation.  There was no prior history and she did not use medication.  She was referred to CMH (Community Mental Health), but did not keep the appointment.  On the DD Form 2807-1 dated 24 August 2006 the CI checked off nervous trouble of any sort (anxiety or panic attacks) and noted “In 2003…I was anxiety.”  At the VA examination for mental disorders dated 13 March 2007 the CI stated she could not think of any particular trigger or cause for her anxiety at the onset of AIT training in 2002 and indicated she took medication for about 2 months and then took herself off the medication.  She noted she had occasional anxiety.  Overall she denied any symptoms of emotional distress and none were noted in the interview.  While deployed she was terrified by mortar attacks and possible gas attacks, but could not name any particular trauma that she experienced since the military.  At the mental status examination she was cheerful and upbeat and indicated she sometimes was anxious and sometimes had panic attacks, but was otherwise normal and had no problem behaviors or occupational or social functional impairment.  At the time of processing through the military disability evaluation system, no obvious or significant change in diagnosis was made at any time.  Therefore, the CI does not appear to meet the inclusion criteria in the Terms of Reference (TOR) of the MH Diagnosis Review Project.

BOARD FINDINGS:  In the matter of the chronic back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended patellofemoral syndrome condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  In the matter of the anxiety condition, the Board unanimously recommends no addition of it as an unfitting condition.  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 20150124, 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, AR20160018846 (PD201500093)

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