RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00197
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20080616

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Food Service Operator, medically separated for “lumbar intervertebral disk syndrome [IVDS],” with a disability rating of 20%.

CI CONTENTION:  The CI states that the severity of his conditions continue to escalate.  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 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 - 20080321	VARD - 20080829	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar IVDS	5243	20%	Status Post L5-S1 Internal Disk Derangement…	5243	10%	20080612	
			Scar; Status Post Diskectomy of the Lumbar Spine	7804	10%	20080612	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began in spring 2007 while running.  The CI denied any specific injury or trauma.  Diagnostic imaging (MRI) showed a herniated disk at L5/S1.  The CI underwent lower back surgery in April 2007.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  An MRI in December 2007 showed a herniation at L5/S1 representing either a persistent fragment or recurrent herniation.  The MEB forwarded “non-radicular pain of lumbosacral spine limiting physical activity” for PEB adjudication.

The MEB NARSUM examination on 19 February 2008, 4 months prior to separation, noted complaints of low back pain which had progressively worsened with a left leg problem having improved somewhat.  The physical examination showed full range of motion (ROM) with some accompanied muscle spasms, tenderness to palpation and an antalgic gait.  Provocative testing for radiculitis (straight leg raise) was positive on the left, there was 4+/5 weakness in the left gastrocnemius muscle, and the left Achilles reflex was absent.  Sensory exam was normal.  Formal physical therapy ROMs dated 4 March 2008 documented painful motion, a forward leaning gait, tenderness, and levoscoliosis.  ROM was forward flexion to 35 degrees (normal 90) and combined ROM was 150 (normal 240).

At the 12 June 2008 VA Compensation and Pension (C&P) evaluation, performed 4 days before separation, the CI reported 6 months of physical therapy which did not improve his lumbar and thoracic spine pain.  The CI also complained of a painful and itchy scar that responded well to heat, ice and rest.  X-ray from November 2006 showed thoracolumbar scoliosis.  An MRI from March 2007 showed an L5/S1 herniated disc producing moderate effacement of the left S1 nerve root.  The physical examination showed a painful ROM to normal limits, mild spasm and mild thoracic scoliosis.  The examiner opined that flexion would decrease to 70 degrees (normal 90) on flare-ups.  The CI walked adequately (not quickly) and there was no antalgia (sign of spinal pain).  Provocative and sensory testing were negative for radiculopathy.  Motor and reflex testing were normal and symmetrical.  The back scar was 6 cm and tender.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 20%, coded 5243 (IVDS), citing limited ROM.  The VA rated the low back condition 10%, also coded 5243 (IVDS), based on the C&P examination 4 days before separation, citing functional loss due to pain.  The VA additionally rated the lumbar surgical scar 10%, coded 7804 (scar(s), unstable or painful).

The Board agreed that a 20% rating, but no higher, was justified for muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, which was reported on the NARSUM examination, or for limited forward flexion from the physical therapy evaluation.  There was no evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.

The Board does not recommend disability rating for scars unless their presence imposes a direct functional limitation that renders the CI unfit.  The lumbar scar did not interfere with wear of military gear and was not painful at the MEB examination.  Any contribution from the scar on ROM limitation was addressed above.  There was insufficient evidence of duty-limiting impairment from the lumbar scar, thus the Board concluded that the scar condition could not be recommended for additional disability rating.

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 lumbar IVDS condition.

BOARD FINDINGS:  In the matter of the lumbar IVDS 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 20150303, 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

19 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018516 (PD201500197)

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