RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00338
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080920

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

CI CONTENTION:  The CI contends that his back condition continues to worsen and negatively impacts his daily activities.  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 - 20080717	VARD - No VA Claim Submitted	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5237	10%	N/A	N/A	N/A	N/A	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Low Back Pain Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in August 2007 after when he fell about 12 feet off the back of a truck, landing on a couch and then falling onto the ground.  Clinic notes indicated chronic back pain treated with narcotics and physical therapy.  At the time of the orthopedic clinic appointment on 11 October 2007, the CI reported back pain, stiffness and pain radiating into the thighs.  On examination there was limited back flexion and extension as charted below.  There was tenderness and slight motor weakness (5-/5 left; 4+/5 right) that was “secondary to his low back pain not because of actual neurologic weakness.”  Sensation and reflexes were normal, and there was negative straight leg raise test bilaterally (for radicular symptoms).  X-rays were summarized as negative except for dextroscoliosis (lateral spinal curve) and a MRI in October 2007 was unremarkable with no disc herniation noted.  There was no surgical indication.  The CI was seen in the emergency department on 15 October 2007 following a motor vehicle crash complaining of neck and back pain.  Examination documented back spasm with normal radiographs.  

A neurologic examination in January 2008 was normal.  There was straight leg raising pain on the left at 30 degrees and on the right 30 – 45 degrees with localized pain (radicular symptoms).  The CI was given a cane for ambulation in February 2008; however, it was felt that the right leg giving out would improve with time as muscle tone and strength were normal.  The narrative summary (NARSUM) dated 5 February 2008 (7 months prior to separation) noted that the CI reported no improvement since his initial injury and that he had worsened over time, with daily pain and stiffness and a shooting pain in the right side and left lower back.  The CI also reported that his right leg gave out more frequently and mentioned that he kept urinating on himself in the 11 days prior to the NARSUM.  

The NARSUM physical examination noted tenderness, with straight leg raising causing pain localized in the lower back.  Motor testing was 5/5 (normal) except for the right thigh flexion which was 4.5/5.  Muscle tone was normal in all areas.  The examiner stated “because of the pain he has a sense of weakness and lack of endurance.  These are not due to intrinsic neuromuscular disease.”  The NARSUM summarized the record of examinations charted below and evaluated the incontinence as functional rather than attributed to any peripheral nerve condition from the CI’s back condition.  Neurologic examination noted decreased “feel to sharp objects throughout the thighs legs and dorsum of the feet.”  The examiner stated that muscle strength was normal “except for right thigh flexion which was 4.5 and that was due to pain.”  There was no VA Compensation and Pension (C&P) examination or VARD in evidence.

The range-of-motion (ROM) evaluations 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)	Ortho ~11 Mos. Pre-Sep	PT ~8 Mos. Pre-Sep	MEB ~7 Mos. Pre-Sep	MEB-PT ~6 Mos. Pre-Sep	
Flexion (90 Normal)	“about 15”	70	25	70	
Combined (240)	Unk/Incomplete	175	Unk/Incomplete	185	
Comment:  	Tender; 4+/5 motor function on right; sensation intact; negative straight leg raise	Tenderness; muscle spasm and guarding; normal gait	Pain limited motion; normal gait	Painful motion; tenderness; spasm/guarding without abnormal gait or contour	
§4.71a Rating	40%	10%	40%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% analogously coded 5299-5237 (lumbosacral strain), citing loss of forward flexion.  The Board considered the probative values of the multiple examinations in evidence.  The orthopedic and NARSUM examinations did not provide complete ROM values, and were more distant than the MEB-PT formal ROM evaluation.  The Board majority adjudged that the MEB-PT examination had the highest probative value for rating at separation.  The Board majority agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) reported on the PT examination 6 months prior to separation.  Although there was muscle spasm, it was not severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had symptoms of radiating pain documented in the treatment records; however, examinations indicated normal reflexes and gait, and the sensory changes did not affect his job.  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 motor weakness which would impact military occupation specific activities.  Although the CI described intermittent episodes of his right leg giving out, examiners indicated that decreased motor testing results were due to pain; there was no objective evidence of peripheral neuromuscular weakness.  The CI’s incontinence was diagnosed as “functional” and not due to peripheral nerve impairment related to the unfitting back condition.  The Board therefore concluded that 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 majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back pain condition.  

BOARD FINDINGS:  In the matter of the low back pain condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  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 20150529, 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, AR20160014252 (PD201500338)

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