RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00213
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E6, Cavalry Scout, medically separated for “chronic subjective back pain” with a disability rating of 10%.   

CI CONTENTION:  The applicant makes no specific contention in their application.  The applicant’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 - 20050831	VARD - 20070312	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Back Pain	5241	10%	Lumbar Fusion at L4-5	5241	10%	20060511	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Back Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), after lifting tents in January 2003 the CI developed low back pain (LBP) that radiated to the backs of his knees.  Lumbar spine magnetic resonance imaging showed multilevel degenerative disc disease (DDD) with bilateral neuroforaminal narrowing and central spinal canal stenosis at L4-5 and the CI underwent surgery for lumbar fusion, in January 2004.  In August 2004 the CI reported persistent severe LBP with flexion that radiated down both lower extremities (LEs).  At a follow-up visit 30 September 2004 with the orthopedic surgeon, X-rays showed “excellent interbody fusion” and the assessment was that the CI was doing well and should continue PT.  PT visits on 27 September 2004 and 4 October 2004 showed flexion “below the knees” with pain.  Three out of four PT visits from 2 November 2004 to 10 December 2004 (11 to 12 months before separation) showed flexion to the mid-tibia with pain, and one showed flexion to the knees after the CI had attempted jogging.  Extension and lateral flexion were indicated to be variable, between 50% decreased and normal, with pain.  

At the MEB examination (recorded on DD Form 2808), dated 21 March 2005, 8 months prior to separation, the physical examination showed a ROM of forward flexion of 85 degrees (90 degrees normal) with a combined ROM of 215 degrees (240 degrees normal).  Lower extremity strength and reflexes were normal and straight leg raise testing (SLR) for radiculopathy was negative (positive if raising the leg to 60 degrees or less reproduces LE symptoms).

The MEB NARSUM physical examination on 3 June 2005 (5 months prior to separation) the showed the CI was “neurologically intact to motor, sensory and reflex in his lower extremities” and SLR was negative.  The surgical incision was well healed.  There was no antalgic gait.  The examiner stated the CI “does have some limitations due to his pain, but on a regular basis he does not.”

At a primary care visit on 24 August 2005, the CI reported no current pain.  He noted that he used anti-inflammatory medication three times daily which worked well and took pain medication occasionally for exacerbations.  The examination noted normal gait, stance, and motor function and the assessment was the back condition was stable.  

At the VA Compensation and Pension (C&P) examination on 11 May 2006, performed 6 months after separation, the CI reported constant pain, graded 9/10, elicited by physical activity, and relieved by rest and medication.  He reported that he could function with the pain with medication and that the back condition did not cause incapacitation.  The physical examination showed normal gait and posture, with no tenderness or muscle spasms.  Bilateral lower extremity strength, sensation, and reflexes were normal and SLR was negative.  There was no ankyloses.  The ROM was forward flexion of 75 degrees (90 degrees normal) with a combined ROM of 205 degrees (240 degrees normal).  Joint function after repetitive use was limited by pain, but was not limited by fatigue, weakness, lack of endurance or incoordination.  There was no additional loss of ROM with repetition or radiating pain with movement.  The VA examiner indicated there were “no signs of intervertebral disc syndrome [IDS] with chronic and permanent nerve root involvement.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% coded 5241 (spinal fusion).  The VA also rated the back condition 10% coded 5241 (spinal fusion), based on the VA C&P examination 6 months after separation, citing limitation of forward flexion and limitation of combined ROM.  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) and combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB and VA examinations.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  The evidence in record supports that following the spinal fusion surgery, the back condition gradually and steadily improved.  Although the CI had degenerative disc disease there were no incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  The Board also considered if there was evidence of a separately unfitting radiculopathy due to the lumbar DDD condition to recommend additional rating at separation.  Although the CI initially reported radiating pain to both lower extremities, which continued after surgery (with flexion) for a time, radiating pain is subsumed under the general spine rating criteria.  By the time of the MEB exams and the C&P exam, there were no LE symptoms reported and the VA examiner indicated there was no evidence of chronic or permanent peripheral nerve impairment due to IDS.  Therefore, the Board concluded additional rating could not be recommended 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 back condition.  

BOARD FINDINGS:  In the matter of the back 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 20150316, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXX, AR20160014242 (PD201500213)

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