RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00149
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Human Resources Specialist, medically separated for “lumbosacral strain” and “shin splints,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI contends that the ratings for his back, sleep apnea, right knee, left knee, and major depressive disorder be changed.  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 - 20071019	VARD – 20080624	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Paravertebral Myositis	5021-5237	20%	20080409	
Shin Splints 	5099-5022 	0%	Left Leg Shin Splints	5299-5262	0%	20080412	
			Right Leg Shin Splints		0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  The PEB combined the right and left shin splints conditions as a single unfitting condition coded analogously to 5022 (periostitis) and rated 0%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The Board also noted that “bundling,” the combining of two or more major joints or related conditions, may be permissible under the VASRD 5003 rating requirements for all applicable codes, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral shin splints conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition was first diagnosed in 2005. The CI reported low back pain (LBP) and left knee pain.  Initially, knee X-rays were negative and the LBP was diagnosed as mechanical LBP.  At the time, the CI was being treated in physical therapy for bilateral knee pain that alternated which side was worse and bilateral lower extremity (LE) pain.  Later PT notes indicated the CI reported increased LBP with radiation to the left knee and thigh and the therapist questioned at that time if the LE pain was related to the back.  The examination noted TTP of the lumbar region and increased back pain with examination maneuvers.  The CI was given back exercises to perform and at the follow-up visit he noted significant improvement in both back and knee pain.  A bone scan of the lower body in April 2007 noted moderate diffuse uptake of the lower extremities bilaterally, interpreted by the radiologist as stress changes versus degenerative changes.  An orthopedic evaluation two weeks later noted the bone scan was normal and showed general joint stress and mild shin splints bilaterally.  At treatment visits after this the CI reported LBP and bilateral lower extremity pain to include hips, knees and ankles. Lumbar spine X-rays in September 2007 were normal.  The MEB forwarded “non-radicular lumbar back pain” for PEB adjudication.  

At the MEB examination on 2 October 2007, 3 months prior to separation, the CI reported LBP and hip, knee, lower leg, and ankle pain.  The physical examination showed decreased ROM of the spine and normal strength, sensation, and reflexes of the LEs.  

The MEB NARSUM examination on 2 October 2007, 3 months prior to separation, noted complaints of daily LBP.  The physical examination showed a normal gait.  There was tenderness to palpation over the lumbar spine.  There was normal LE strength and reflexes.  Physical therapy performed ROM for the MEB the same day.  Thoracolumbar ROM after three repetitions was flexion 55 degrees (normal 90 degrees) and combined ROM of 170 degrees (normal 240 degrees. The therapist noted normal gait and contour and TTP of the lower lumbar spine.  

The 9 April 2008 VA Compensation and Pension (C&P) Spine evaluation, 3 months after separation, noted a diagnosis of lumbago.  The CI reported the LBP was progressively worsening and denied radiation.  He reported decreased motion, stiffness, weakness, and spasms.  He reported flare-ups aggravated by prolonged sitting and driving.  He reported difficulty standing up from bed during flare-ups and recommended exercises made him worse.  The physical examination noted an antalgic gait and lumbar flattening (abnormal spinal contour).  There was tenderness, muscle spasm, and pain with motion.  The examiner indicated the muscle spasm was not severe enough to result on an abnormal gait or abnormal spinal contour.  Lower extremity strength, sensation, and reflexes were normal and no abnormal reflexes were present.  Thoracolumbar ROM was flexion of 50 degrees which decreased to 45 degrees and combined ROM of 130 degrees which decreased to 105 degrees after repetition due to pain.  Testing for radicular signs was positive on the right.  Testing was performed for non-organic physical signs and 4/5 were negative.  Lumbosacral spine films were read as paravertebral muscle spasm.  

A VA outpatient neurosurgery consult on 19 May 2008, 5 months after separation, the CI reported constant LBP radiating to the right LE with numbness.  He denied bladder problems.  The physical examination noted normal strength and reflexes and testing for radicular signs was positive.  A lumbar MRI on 23 April 2008 showed severe degenerative changes and herniated discs at L4-L5 and L5-S1 and surgery was recommended for decompression and fusion.  The CI underwent surgery on 7 August 2008, 8 months after separation.  The operative note indicated symptoms of back pain with radiation to the legs with difficulty walking due to the severity of the pain and operative findings noted compression of the spinal nerve roots and spinal canal stenosis at both L4-5 and L5-S1 levels.  Notes after surgery indicated the CI continued to report LBP but no radiculopathy.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing tenderness and ROM limited by pain.  The VA rated the back condition 20% coded 5021-5237 (myositis- lumbosacral strain) based on the VA C&P examination 3 months after separation, citing limitation of motion. 

The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) noted at the MEB NARSUM and VA C&P examinations and combined ROM not greater than 120 degrees reported on the VA examination.  Although the CI did have intervertebral disc syndrome (IVDS), there was no evidence of 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 recommends a disability rating of 20% for the low back condition, coded 5299-5237.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  During active duty the CI was not diagnosed with a radiculopathy.  However, he reported LBP and bilateral LE pain.  Prior to separation no additional imaging of the spine was performed, but it appears that shortly after separation MRI showed severe degenerative disc disease (DDD), herniated discs, and spinal stenosis that, based on the surgeon’s operative note, were causing spinal nerve root compression as well as spinal stenosis that can cause radiating pain that is more vague in distribution.  However, there was no documentation in record of abnormal LE strength, sensation, or reflexes either prior to separation or after separation and before his back surgery.  Radiating back pain is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no evidence in this case that motor weakness or a sensory deficit related to the low back condition 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. 

Shin Splints.  According to STRs and the MEB NARSUM, the CI’s shin splints first presented in December 2005 during basic training.  The CI sought treatment for left and right knee pain and then anterior lower leg pain, and later progressed to include the hips, knees, ankles, and lower legs.  As noted above, in April 2007 a bone scan of the lower body noted moderate diffuse uptake of the LE bilaterally, interpreted as stress changes versus degenerative changes.  The orthopedic evaluation two weeks later noted the bone scan was normal and showed general joint stress and mild shin splints bilaterally.  Also as noted above, the Board considered that much, if not all, of the bilateral LE pain in the hips, knees, and to the ankles may have been a sequelae of severe DDD, spinal stenosis and lumbar disc herniation identified shortly after separation.  In June 2007, a primary care note indicated the CI was given a P2 profile due to difficulty standing all day and lifting heavy objects and was referred to a MOS Medical Review Board.  At the next follow up visit in late August 2007 the CI reported he was much improved, but his job still aggravated his left knee pain and he was also going to find out if he could change jobs that day.  An internal medicine note in September 2007 indicated the CI was in the MEB process for back pain and LE pain.  He reported he had passed an Army Physical Fitness Test in July 2007 with the walk test instead of a run event.  The MEB forwarded “stress reactive bone changes to bilateral lower extremities” for PEB adjudication.  

At the MEB examination the CI reported back pain and hip, knee, and ankle pain.  Physical examination showed decreased ROM of the LEs.  The MEB NARSUM examination noted complaints of chronic bilateral LE pain.  The physical examination noted a normal gait and station.  There was normal muscle strength, tone, and bulk.  There was a positive patellar grind noted.  

At the 9 April 2008 VA C&P Bones evaluation, performed 3 months after separation, the CI reported bilateral anterior lower leg pain, aggravated by weight bearing activities.  The pain was improved by rest, anti-inflammatory medication, over the counter topical ointments and heat. The physical examination showed tenderness to palpation of the anterior tibial borders without swelling redness or warmth noted.  Tibia and fibula X-rays were normal.  The diagnosis was bilateral shin splints.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition 0%, coded 5099-5022 (analogous to periostitis).  The VA rated the left and right shin splint conditions 0% each, coded 5299-5262 (analogous to tibial impairment) based on the VA C&P examination 3 months after separation, citing tenderness without X-ray abnormalities.  The Board first considered if both right and left shin splint conditions remained separately unfitting when separated from the PEB’s combined adjudication as elaborated above. The permanent profile listed bilateral leg pain.  The commander’s statement noted the CI’s limitations due to leg pain and the permanent P2 profile (for lower extremity pain) with physical limitations including no running or road marching and walk and other exercise at own pace and distance.  The CI reported pain in both legs with running.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that each of the bundled shin splint conditions was reasonably considered separately unfitting.  

The Board then considered its rating recommendations for the unfitting shin splints conditions together at the time of separation.  There was evidence on the bone scan of mild shin splints bilaterally.  However, the CI was then on multiple profiles and a permanent P2 profile beginning in June 2004, which would be anticipated to improve mild shin splints.  He did indicate that he was much improved with the profile, but from the STR it appeared that his back condition worsened with bilateral LE pain that was confounding the clinical picture.  As noted above, the Board considered much, if not all, of the bilateral LE pain in the hips, knees, and to the ankles may have been a sequelae of severe DDD, spinal stenosis and lumbar disc herniation identified shortly after separation.  At the VA C&P exam, bilateral lower leg X-rays were normal.  VA treatment notes following the CI’s back surgery noted his LE pain was improved.  The Board concluded that there was insufficient evidence to recommend greater than 0% rating for either the right or left shin splint condition at separation as it was impossible to identify any disability due to shin splint pain as distinct from the radiating pain from the back condition.  Thus, having unbundled the shin splints conditions, the Board found there was no ratings benefit to the CI and therefore, recommends no change to the PEB’s combined adjudication.  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 bilateral shin splints condition.  

BOARD FINDINGS:  In the matter of the lumbosacral strain condition, the Board unanimously recommends a disability rating of 20%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the bilateral shin splints 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation: 

CONDITION	VASRD CODE	PERMANENT RATING	
Lumbosacral Strain	5237	20%	
Shin Splints	5099-5022	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150209, 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

21 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018494 (PD201500149)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA