RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01001
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030216

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Automated Logistical Specialist, medically separated for “chronic low back pain (LBP) with coccydynia, without neurologic abnormality or documented chronic paravertebral muscle spasms on repeated examinations with characteristic pain on motion” 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 – 20021216	VARD - 20030122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP with Coccydynia	5299-5295	10%	Degenerative Disc Disease (DDD) of the Lumbar Spine with Coccydynia	5292-5293	10%	20020923	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic LBP condition began in approximately 1997 after a remote history of a fall when he landed on his coccygeal region of the spine and after a lifting injury.  He experienced an immediate onset of pain with each episode and was treated conservatively in 1998 with physical therapy, Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)), and Norflex (orfenadrine, a muscle relaxer).  Back pain flared with running.  An X-ray series of the lumbar spine was normal in June 1999 and on examination the CI had tenderness to palpation at the sacrum, but no tenderness of the lumbar area.  Magnetic resonance imaging (MRI) on 10 September 1999 demonstrated a desiccated disc at L5-S1 and tearing of the outer annulus fibers.  At L5-S1, there was a small focal central disc protrusion without contact of the right or left S1 nerve roots within the lateral recess, and the left and right neural foramina (where nerves pass through the vertebral column) were patent.  In September 1999 the CI’s left leg length was noted to be 1.25 cm greater than the right leg.  Orthopedic evaluation 7 February 2000 noted the CI had no radicular symptoms, but he felt a “tingle.”  Examination findings were non-focal.  In 2000 he underwent a Military Medical Review Board, but he decided to work through it and remain in his MOS.  On 17 December 2001 the CI reported increased pain with activity.  He had no sexual dysfunction or bowel or bladder dysfunction, but noted he was unable to function at an adequate level.  An orthopedic note dated 26 August 2002 indicated the CI was offered a trial in the pain clinic or with a chiropractor, but the CI refused both options.  Despite treatment, the chronic low back pain 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 “coccydynia with mild degenerative disc disease” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807-1 and 2808) on 17 September 2002, 5 months prior to separation, the CI reported lower back pain in the tailbone area.    The examiner noted normal straight leg raise to 100 degrees seated and supine.  Standing forward flexion was to 80 degrees.  The CI reported pain with bent knee/hip flexion on the right in the lower back.  There was tenderness to palpation from L3 to the coccygeal region and there was a normal heel/toe gait.  At the NARSUM examination dated 17 September 2002, 5 months prior to separation, the CI described pain each morning on rising at 6.5-7/10 (10 being the worst pain).  Pain improved with stretching and activity, but was still worrisome by the evening.  He took Naprosyn (naproxen, an NSAID) and Flexeril (cyclobenzaprine, a muscle relaxer) to control his symptoms.  Physical therapy did not provide prolonged improvement.  On examination of the spine, standing [flexion] was 90 degrees, extension 20 degrees, and lateral bending 35 degrees.  While supine, the CI reported lower back pain with right hip flexion with the knee flexed and denied pain with a right straight-leg raise.  Seated examination demonstrated no pain with bilateral straight-leg raise (to determine nerve root irritation) to 100 degrees.  He was able to fully don and doff socks and shoes from a standing position with full range of motion (ROM) demonstrated.  A normal heel-to-toe gait was demonstrated.  There was tenderness to palpation from L3 to the coccygeal region.  Muscle strength was 5/5 throughout and neurological evaluation was unremarkable.  Despite multiple treatments, which included physical therapy, profiling and NSAIDS, the CI still had periodic exacerbations of LBP with some chronic LBP all the time, which limited his day-to-day activity.  The examiner’s diagnosis was coccydynia (pain in the coccyx) with mild degenerative disk disease at L5-S1.  An X-ray series of the lumbar spine was normal in September 2002. 

The VA Compensation and Pension (C&P) evaluation was based on the NARSUM examination performed on 17 September 2002 and was dated 23 September 2002, 5 months before separation.  The CI reported pain each morning on arising and pain affected his ability to sleep.  It also occurred with sit-ups and he was guarded with all lifting greater than 50-60 pounds.  On examination he had a normal gait and normal posture.  The remainder of VA examination incorporated the findings of the NARSUM examination as noted above.  An X-ray series of the lumbosacral spine in June 2004, 16 months post-separation, was normal.   

The 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 5 Mos. Pre-Sep
	VA 4.90 Mos. Pre-Sep
	
Flexion (90 Normal)	90	90	
Extension (30)	20	20	
R Lat Flex (30)	30 (35)	30 (35)	
L Lat Flex (30)	30 (35)	30 (35)	
R Rotation (30)	-		
L Rotation (30)	-		
Combined (240)	-		
Comments	Painful motion; straight leg raise to 100 degrees; tenderness L3 coccygeal region; motor, reflexes normal	Gait normal; Painful motion; straight leg raise to 100 degrees; tenderness L3 coccygeal region; motor, reflexes normal	
§4.71a Rating	PEB 10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for the chronic low back pain with coccydynia under an analogous code 5299-5295 (Lumbosacral strain:  With characteristic pain on motion), citing characteristic pain on motion IAW DoDI 1332.39.  The VA also assigned a 10% rating using an analogous code 5292-5293 (Spine, limitation of motion of, lumbar (slight)-Intervertebral disc syndrome (mild)).  Based on the CI’s date of separation, VASRD interim spine rules were applied.  The Board agreed a 10% rating was justified for the presence of characteristic pain on motion.  However, there was no muscle spasm on extreme forward bending or loss of lateral spine motion (unilateral, in standing position) to warrant a higher 20% rating.  The Board also considered rating the back condition using VASRD diagnostic code 5293 based on incapacitating episodes due to intervertebral disc syndrome.  The criteria are based on the number of incapacitating episodes in the prior 12 months requiring bed rest prescribed by a physician.  No documented physician-directed bed rest was evidence in the service treatment records or at the time of the C&P examination.  The Board concluded the evidence did not support a higher rating using this code. Furthermore, there was insufficient evidence of ratable peripheral nerve impairment which would provide for additional rating.  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 chronic low back pain condition.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously 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

AR20170005502, XXXXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure