RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00671
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070613

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E3, Carpentry/Masonry Specialist, medically separated for “thoracolumbar degenerative disc disease…,” with a disability rating of 10%.

CI CONTENTION:  The CI did not submit a contention in the application.  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 - 20070524	VARD – 20081205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracolumbar Degenerative Disc Disease	5299-5242	10%	T5-T7 Thoracic Spine Degenerative Disease	5243	10%	20081112	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:  

Thoracolumbar Degenerative Disc Disease.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in January 2003 after attempting to catch a falling heavy object.  Radiographic studies initially showed no abnormality but later revealed disc protrusions at T5-T6 and T6-T7 causing some spinal canal stenosis without evidence of cord compression.  There was no surgical indication.  A primary care visit on 12 February 2007, 4 months before separation, the CI reported a history of three years of back pain with an increase in the past 3 days of mid-back pain without radiation to the upper or lower extremities or neurological symptoms.  The exam noted normal gait and stance.  There was thoracic muscle spasm with normal thoracolumbar range of motion (ROM).  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “thoracic intravetrebral disc degeneration with chronic midback pain (sic)” for PEB adjudication.  The range of motion (ROM) examinations 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)	MEB NARSUM ~3 Mos. Pre-Sep	VA ~17 Mos. Post-Sep	
Flexion (90 Normal)	60, 63,64 (65) 	0-95 (90)	
Combined (240)	195	240	
Comments	ROM limited by pain	Normal Gait and posture	
§4.71a Rating	10%	10%	

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 23 March 2007, 3 months prior to separation, the CI reported sharp pains in his back resulting in temporary loss of feeling in right arm.  Physical examination showed muscle tenderness at the mid thoracic level, normal heel and toe walk (absence of muscle weakness due to radiculopathy), and normal strength, sensation.  Lower extremity reflexes were normal and straight leg raise testing to elicit lumbar radicular symptoms was negative.  Thoracolumbar ROM was as recorded in the chart above.  The MEB NARSUM examination on 23 Mar 2007, 3 months prior to separation, CI complained of experiencing daily pain despite the use of anti-inflammatory and muscle relaxers.  Physical examination showed the same findings as the DD Form 2808 dated 23 March 2007.

At the 12 November 2008 VA Compensation and Pension (C&P) evaluation, performed 17 months after separation, the CI reported daily pain that ranged from 3-9/10, described as deep aches but also shooting in nature.  He reported decreased motion, stiffness, spasms, and fatigue of his back.  Flares were reported 1-2 times per month and increasing.  He could walk 1 to 3 miles, but reported he needed to be very careful with his ROM or he would trigger shooting pain.  He denied any periods of incapacitation in the past 12 months.  Physical examination showed a normal gait and spinal contour.  There was right thoracic tenderness, muscle spasm, guarding, and painful motion.  Strength, sensation, and reflexes were normal throughout.  Thoracolumbar ROM was as recorded in the chart above.  There was painful motion noted with no additional loss of ROM with repetition.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5242 (degenerative arthritis of the spine), citing tenderness and range of motion limited by pain.  The VA also rated the back condition 10% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 17 months after separation, citing forward flexion.  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/or combined ROM (greater than 120 degrees but not greater than 235 degrees) and/or tenderness reported on all exams.  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.  There was no documentation of incapacitating episodes which would provide for a higher rating.  Although the CI experienced radiating pain, there was no objective evidence of a radiculopathy or functional impairment with a direct impact on fitness and 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 is no evidence in this case that there was radiculopathy with associated functional impairments that were separately functionally impairing.  The Board therefore concludes 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 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 or majority 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 20150603, 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 
XXXXXXXXXXXXXXXXXX, AR20170002442 (PD201500671)

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