RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00517
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051104

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Unit Supply Specialist, medically separated for “chronic low back pain and localized T5 level pain,” with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention.  The 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 - 20051007	VARD - 20060802	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain, Localized T5 Level 	5299-5237	10%	Lumbosacral Strain	5237	20%	20060415	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain and Localized T5 Level Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed thoracic and low back pain in 2003 without a specific precipitant.  It persisted and was exacerbated by various lifting incidents over time.  All imaging (X-ray, MRI, bone scan) was normal.  Outpatient notes in the STR indicated the absence of pain radiation or radicular symptoms (no sensory or motor); and, multiple neurologic examinations were normal.  The latter included a neurology consult in August 2005 (3 months before separation); and, there was no STR evidence to the contrary.  There was a physical therapy (PT) consult in April 2004 that documented “chronic right facet vs. costovertebral joint dysfunction at T5.”  There were multiple STR entries documenting grossly normal (the great majority) or non-specifically limited thoracolumbar range of motion (ROM), with none indicating severe limitation.  There was occasional note of abnormal spinal contour (no correlation with spasm or guarding), but other entries to the opposite; and, there were multiple entries documenting a normal gait with no contrary entries.  There was no STR documentation of incapacitating episodes.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for MEB.  The MEB forwarded “lumbago,” and “T5 neuritis” to the PEB.  

The NARSUM examination in July 2005, 4 months before separation, documented “moderate constant pain in the thoracic T5 area on the right ... [and] ... the lumbar spine on the left side,” elaborating only profile restrictions as functional limitations.  The physical examination recorded tenderness “from T10 to L3,” the absence of spasm (no comment regarding gait or spinal contour), and referenced the MEB’s DD Form 2808 physical examination which reflected grossly normal neurologic findings.  The ROM measurements recorded in the NARSUM were flexion to 30 degrees (rounded from 32, normal 90) with a combined ROM of 90 degrees (normal 240).  

The NARSUM referenced the above PT opinion regarding the T5 diagnosis, and this was the only link to the separate submission of T5 neuritis to the PEB.  The NARSUM examiner assigned a U1/L3 profile, although the permanent profile of record listed a U3 profile associated with “T5 radiculopathy.”  The commander’s performance statement acknowledged “T5 radiculopathy in his back,” but did not document any MOS limitations specific to the upper body or arms.  

At the 15 April 2006 VA Compensation and Pension (C&P) examination, 6 months after separation, documented constant “mid to lower back” pain rated 6/10 that “travels to his knees” (no mention of sensory or motor complaints) and was aggravated by prolonged standing.  The examiner specified the absence of incapacitation.  The physical examination recorded a normal gait and spinal curvature, no spasm or tenderness, and normal neurologic findings (motor, sensory, reflexes).  The ROM measurements were flexion to 60 degrees with combined 205 degrees.  The VA examiner did not diagnose an associated neuropathy.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB subsumed both MEB submissions as a single unfitting condition rated 10% under code 5299-5237 (analogous to thoracolumbar strain), citing “[ROM] limited by pain” with likely application of Army Regulation (AR) 635-40 (B-29, e).  The VA rated under code 5237 and cited the C&P measurement of flexion to 60 degrees as meeting the VASRD §4.71a criterion of flexion “greater than 30 degrees but not greater than 60 degrees” for its 20% determination.  The Board considered that the NARSUM evidence of flexion to 30 degrees (when rounded IAW §4.71a) met the 40% criterion of flexion “30 degrees or less.”  Members agreed, however, that the great preponderance of ROM evidence, the overall clinical pathology, and the functional disability in evidence did not support concession of the determinant probative value to this singe flexion measurement at the cusp of the higher rating; thus, concluding that the determinant probative value was fairly assigned to the C&P ROM evidence.  There was no documentation of incapacitating episodes or diagnosis of intervertebral disc syndrome that would provide for a higher rating under that formula.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to the T5 neuritis.  The clinical evidence confirmed that symptoms were related to local nerve root irritation (e.g., integral to the spinal pain), and there was no accompanying subjective or objective motor or sensory component as a basis for functional limitations.  The pain from the neuritis was thus intrinsic to the ROM limitation and §4.71a rating for the spine, and no additional rating was justified in compliance with VASRD §4.14 (avoidance of pyramiding).  The Board therefore concluded that a separate disability rating could not supported on this basis.  

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 lumbar spine condition (subsuming the T5 neuritis), preferring the PEB code 5299-5237.  

BOARD FINDINGS:  In the matter of the lumbar spine condition (subsuming the T5 neuritis), the Board unanimously recommends a disability rating of 20%, coded 5299-5237 IAW VASRD §4.71a.  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	
Thoracolumbar Strain with Localized T5 Neuritis	5299-5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160018738 (PD201500517)

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