RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00834
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091126

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

CI CONTENTION:  “Review all conditions.”  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 - 20090821	VARD - 20100420	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain 	5299-5237	10%	Lumbar Spine Strain, DDD at L3, S1 with Radiating Pain to Right Hip	5242	0%	20091021	
Refractive Error	Not Unfitting	No VA Placement	
Right Wrist Pain	Not Unfitting	Right Wrist, Overuse Tendonitis, Mild	5024	0%	20091021	
Idiopathic Hypersomnia	Not Unfitting	No VA Placement	
Acne	Not Unfitting	Facial and Right Arm Acne	7828	0%	20091021	
Irregular Menses	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

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 September 2007 after heavy lifting.  Radiographic studies showed lumbar scoliosis (abnormal lateral curve) as well as multi-level degenerative disc disease (DDD) from L3 to S1 without impingement on nerve structures.  
Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and she was referred for an MEB.  The MEB forwarded “chronic low back pain” 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)	PT ~6 Mos. Pre-Sep	MEB ~4 Mos. Pre-Sep	Chiro ~3 Mos. Pre-Sep	VA ~1 Mo. Pre-Sep	
Flexion (90 Normal)	60	85	10	90	
Combined (240)	185	230	~120	240	
Comments	Painful motion and scoliosis	Painful motion and tenderness	Following acute injury; spasm; painful motion; tenderness; and “abnormal appearance of the lumbar spine”	Tenderness	
§4.71a Rating	20%	10%	Unk-40%	10% (VA 0%)	

At the time of the physical therapy (PT) clinic appointment on 28 May 2009, 6 months prior to separation, the CI reported a history of right leg pain down to the ankle.  She also reported 4 out of 10 back pain that was aggravated by sitting or standing longer than 20 minutes.  On examination she was noted to have limited motion as indicated in the chart above with pain on extension.  There was no tenderness or increased lordosis and her gait was normal.  Her motor strength was 4-/5 in the bilateral lower extremities, but examination tests for radicular symptoms were negative and she had normal reflexes and sensation.  

The MEB NARSUM examination on 10 August 2009, 4 months prior to separation, noted complaints of back pain, rated at 6 of 10, radiating into her right hip and ankle.  Her pain was aggravated with prolonged standing, prolonged sitting and impact activities.  Physical examination showed slightly decreased ROM as indicated in the chart above with pain in all planes of motion.  The examiner recorded that all ROM measurements were assessed with a standard goniometer.  The CI had tenderness but no palpable spasms.  Her gait and spinal contour were normal.  Examination tests for radicular symptoms were negative and she had normal motor strength and sensation in her lower extremities.  

At the time of the chiropractic clinic appointment on 26 August 2009, 3 months prior to separation, the CI reported 6 of 10 back pain after she “pulled her right lower back” while doing physical training.  She also reported a history of “lower back pain radiating to the legs” and “numbness of the left leg.”  On examination there was tenderness, muscle spasms, and an “abnormal appearance” to the lumbosacral spine.  Thoracolumbar ROM was severely restricted as indicated in the chart above and pain was elicited with ROM movements.  Gait was normal.  

At the 21 October 2009 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported constant mild back pain that was aggravated by sitting or standing for prolonged periods of time.  She denied having incapacitating episodes of back pain in the past 12 months.  Physical examination showed normal ROM as indicated in the chart above with no report of pain or other functional limitation with repetitive motion.  The CI demonstrated normal spinal contour and gait without spasm or guarding, but she did have mild tenderness to palpation of the lumbar spine.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5237 (analogous to lumbosacral strain), citing limitation of ROM (combined 235 degrees).  
The VA rated the back condition 0%, coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 1 month before separation, citing “forward flexion of the thoracolumbar spine of greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 235 degrees.”  

In assigning probative value to these somewhat conflicting examinations, the Board noted that the MEB and VA examinations were fairly consistent and both included ROM after repetition and both were conducted using a goniometer which is the VASRD standard for rating disabilities.  The chiropractic examination was an inconsistent and transient finding following an acute injury (consistent with a flare of back pain) that responded to treatment, resulting in improved ROM and resolution of spasms by the time of the pre-separation VA examination.  Therefore, based on all the evidence and the associated conclusions just elaborated, Board consensus was that preponderant probative value should be assigned to the MEB NARSUM and VA examinations.  

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; or the presence of tenderness as reported on the MEB examination, or tenderness on the VA examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  

There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported a history of radicular pain and there were symptoms of radiating pain documented in the treatment records; however, examinations proximate to separation indicated normal strength, reflexes, sensation and gait.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  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.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that 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 that there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

Contended PEB Conditions:  Refractive Error, Right Wrist Pain, Idiopathic Hypersomnia, Acne, and Irregular Menses.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any 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 any 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 refractive error, right wrist pain, idiopathic hypersomnia, acne, and irregular menses conditions, 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 20150604, with attachments
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, AR20170000099 (PD201500834)

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