RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00734
BRANCH OF SERVICE: Army 	                      SEPARATION DATE:  20091208

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a drilling National Guard E4, Wheeled Vehicle Mechanic, medically separated for a low back condition, rated at 10%. 

CI CONTENTION:  The CI contends for his unfitting back condition. 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 - 20091021	VARD - 20090203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis of the Thoracolumbar Spine	5242	10%	Low Back Condition	5243	NSC	20080918	
RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:    

Thoracolumbar Spine Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s condition began in April 2007 after doing a road march with full combat gear while mobilized.  The CI denied any specific injury or trauma.  Magnetic resonance imaging (MRI) in July 2007 showed central bulging of L4-5 and L5-S1 discs.  He was treated conservatively, and there was no surgical indication.    

At the VA Compensation and Pension (C&P) examination on 18 September 2008 (15 months prior to separation), the CI reported pain in the low center of the back that was constant, mild, and sharp, and brought on by bending, lifting or carrying.  Pain radiated to both buttocks and the back of the left leg, and was associated with numbness and paresthesias, but not leg or foot weakness.  Assistive devices were not used.  There were no reported incapacitating episodes in the previous 12 months.  Physical examination showed a normal gait and spinal contour.  Guarding, spasm, tenderness and painful motion were absent.  Lower extremity neurologic findings were normal.  Thoracolumbar flexion was 90 degrees (normal 90 degrees) and combined range-of-motion (ROM) was 240 degrees (normal 240 degrees).  There was no loss or alteration of motion after repetitive use.  X-rays were normal.

The MEB examination (recorded on DD Form 2808) on 22 May 2009 (7 months prior to separation) showed decreased forward flexion, but measurement was not performed.  The examiner diagnosed chronic low back pain.  Goniometric ROM performed by physical therapy (PT) on 2 June 2009 (6 months prior to separation) recorded flexion of 75 degrees and combined ROM of 180 degrees.  Painful motion was present.  Guarding was also noted but did not result in abnormal gait or spinal contour.

At an orthopedic clinic appointment on 19 June 2009, the CI reported pain with extended standing, runs, marching, long drives, and military duties (and his MOS duties as a motor vehicle mechanic).  He denied radiating pain, weakness, or numbness.  Examination showed a normal gait.  An abnormal appearance of the spine was noted, but a specific abnormality was not described.  Painful motion was present, but spasm was absent.  Flexion was 90 degrees and all other planes of motion were “normal.”  X-rays showed mild degenerative joint disease.  

The MEB NARSUM examination on 21 September 2009 (3 months prior to separation) noted complaints of “chronic lumbar pain, 100% of the time.”  Pain was rated 3/10 with rest and medication (Tylenol and Motrin at the time), up to 7/10 with activity (lifting more than 15 pounds, repeated squatting or bending, running, jumping, or strenuous activity).  The CI reported being able to do his sedentary duties as a civilian corrections officer.  Physical examination showed paravertebral muscle spasm and some flattening of the lower lumbar spine.  Tenderness and “mildly limited ROM” were noted, but measurements were not provided.  Lower extremity muscle strength was normal.  The examiner diagnosed chronic low back pain. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5242 code (degenerative arthritis of the spine), citing limitation of motion as the rating rationale.  The VA determined the condition was not service-connected (NSC), and used the 5243 code (intervertebral disc syndrome) based on the VA C&P examination 15 months before separation, citing lack of evidence the condition was incurred or aggravated while on active duty.  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 PT examination.  A 10% rating was also supported by the presence of tenderness and painful motion reported by the orthopedic examiner.  In considering other pathways to a higher rating, it was noted that muscle spasm associated with an abnormal spinal contour was possibly present on the NARSUM exam, although this was an inconsistent finding.  The Board majority concluded that this was not a sufficient basis for a 20% rating (i.e. for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis).  There was no documentation of incapacitating episodes which might provide for a higher rating under that formula.  Likewise, there was no associated radiculopathy for separate peripheral nerve rating.  Although the CI experienced radiating pain, there was no objective evidence of a radiculopathy or functional impairment with a direct impact on fitness.  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 is no evidence in this case that there was radiculopathy with associated functional impairments separately functionally impairing.  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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the thoracolumbar spine condition.

BOARD FINDINGS:  In the matter of the degenerative arthritis of the thoracolumbar spine condition and IAW VASRD §4.71a, the Board by a majority vote, recommends no change in the PEB adjudication.  The single voter of dissent did not elect to submit a minority opinion.  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

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, AR20160015155 (PD201500734)

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