RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00273
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050714

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Imagery Analyst, medically separated for “chronic low back pain,” with a disability rating of 10%.

CI CONTENTION:  The CI contends that he had a stroke in 2002 while in the military that wasn’t discovered until recently and should have been rated at 100%.  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 on 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 - 20050329	VARD - 20060222	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	10%	Chronic Low Back Strain	5237	10%	20051116	
Anxiety Disorder	Not Unfitting	Generalized Anxiety with Panic Disorder	9412-9400	10%	20051108	
Hypothyroidism		Hypothyroidism with Residual Weight Gain	7903	10%	20051116	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain [LBP].  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in November 1995 after heavy lifting and was later aggravated in a motor vehicle accident in February 1996.  Subsequent electrodiagnostic and radiographic studies were normal.  Despite treatment, the back condition continued to deteriorate through the years until the CI could no longer meet the physical requirements of his military specialty, and he was referred for an MEB.  The MEB forwarded chronic LBP for PEB adjudication.

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 3 December 2005, 7 months prior to separation, the CI reported back pain that occasionally radiated down the back of his right leg to his heel.  The physical examination showed lumbar paraspinal tenderness, an antalgic gait and altered spinal contour, but was silent with respect to spasm or guarding.  Examination tests for radicular symptoms were negative and the CI’s motor strength, reflexes and sensation were all normal.  At the time of the physical therapy evaluation on 8 February 2005, 5 months prior to separation, the CI reported constant LBP at 7/10 on the pain scale.  Thoracolumbar flexion was 85 degrees (normal 90) and combined range of motion (ROM) was 215 degrees (normal 240).  Painful motion was present.  At the MEB NARSUM examination on 11 February 2005, the CI reported he had severe intermittent pain of the right lower lumbar region during and after activity at the 10/10 level on the pain scale.  His pain was exacerbated by prolonged standing, walking and lifting.  Physical examination showed an antalgic gait and altered spinal contour, but there was no spasm and the examination was silent about guarding.  Tenderness and painful motion were present.  Examination tests for radicular symptoms were negative and motor strength, reflexes and sensation were all normal.  

At the 16 November 2005 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported low back pain at 9/10 on the pain severity scale.  He also complained of sharp pain radiating from the back into the legs and heels. Physical activity worsened his symptoms.  Incapacitation was denied.  He was able to walk, climb stairs, shop, vacuum, perform gardening and push a lawn mower.  Physical examination showed painless ROM.  Flexion was 90 degrees and combined ROM was 240 degrees; however there was tenderness of the thoracolumbar spine.  The examiner noted no pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  Motor strength, sensation, reflexes, gait and posture were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain).  The VA also rated the condition 10% under the same code, based on the VA C&P examination 4 months after separation, citing evidence of tenderness as the rationale. 

The Board agreed that a 10% rating, but no higher, was justified for limitation of motion reported by the service PT examiner.  The presence of tenderness and painful motion were alternate routes to a 10% rating.  Although there was an antalgic gait and altered spinal contour noted by the MEB and NARSUM examiners, this was an inconsistent finding and there was no requisite link to muscle spasm or guarding; 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 if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  Radiologic studies showed no evidence of lumbar nerve root involvement, the electro-diagnostic studies showed no evidence of neuropathy or radiculopathy, and neurologic examinations were normal.  While the CI may have experienced radiating pain from the back condition, this 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 objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board concluded 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 there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain condition.  

Contended PEB Conditions:  Anxiety Disorder and Hypothyroidism.  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, 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.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder and hypothyroidism, 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 20150422, 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

06 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002586 (PD201500273)

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