RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01459
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040807

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Unit Supply Specialist Trainee, medically separated for “chronic low back pain with tenderness from L4 to sacrum,” with a disability rating of 0%.  

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 - 20040621	VARD – No VA Claim	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back	5299-5237	0%	NA	
Sacroiliac Joint Dysfunction	Not Unfitting		
Cervical Dysplasia	Not Unfitting		
Spina Bifida Occulta	Not Unfitting		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (Subsuming SIJ Dysfunction). The Board first noted that although sacroiliac joint (SIJ) dysfunction was separately adjudicated from the overall lumbar condition by the PEB, it was not subject to separate rating IAW VASRD §4.71a.  The option of rating under code 5236 (sacroiliac injury and weakness) is available under the §4.71a general rating formula for the spine, but it may not be added to another lumbar spine code for separate rating without violation of VASRD §4.14 (avoidance of pyramiding).  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed atraumatic low back pain radiating to the left SIJ in basic training (11 months before separation).  The pain radiated down the left lower extremity (LLE) with an occasional note of “tingling” but no complaint of weakness.  There were multiple normal neurological examinations in STR clinical entries, with none to the contrary; and, imaging (MRI) was normal.  There were entries confirming the presence of SIJ tenderness, although others noted left hip tenderness and/or painful motion of the joint.  

There were some STR entries that documented grossly normal range of motion (ROM), although there were others that noted non-specifically decreased or modestly limited ROM.  There were no entries indicating severe ROM limitation, but there was documentation of painful motion.  The physical therapy ROM measurements for the MEB were presented in an atypical format (not as degrees measured by a goniometer) that could not be interpreted without speculation, but appeared to reflect modest limitations only.  A gait disturbance was documented in multiple STR clinical entries, with descriptions ranging from “antalgic,” to “stooped,” to “slowed.”  This appeared to be linked to SIJ pain, although that was not clear; and, there was no clear correlation with spasm or guarding (albeit implied in a few instances).  There was no STR documentation of abnormal spinal contour or 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 an MEB which in turn forwarded “chronic lower back pain” and “[SIJ] dysfunction” to the PEB.

The NARSUM examination on 4 April 2004 (4 months before separation) documented lower back and left SIJ pain with LLE radiation (no mention of motor or sensory symptoms) rated 3/10 “at rest” with exacerbations to 10/10 by “jumping, running, walking long distances and prolonged standing.”  The physical examination recorded “antalgic gait,” tenderness without note of spasm or guarding, and “full active [ROM] in flexion and left side bending” (painful motion not addressed).  Neurological findings were normal with the exception of “4/5 flexion of the right hip;” but, there was insufficient documentation to link that finding, contralateral to the symptoms and uncorroborated by any other examiner, with neurological weakness (especially with no pathological explanation).  There was no VA claim or other post-separation evidence in this case.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating under code 5299-5237 (analogous to lumbosacral strain) cited only “full active flexion ... no focal neurological deficit.”  Members agreed, however, that VASRD §4.59 (painful motion) and/or §4.40 (functional loss) was reasonably supported by the evidence and fairly conceded in support of the minimum compensable 10% rating.  Members further agreed that there was insufficient ROM evidence to support a rating higher than 10%.  There was no evidence of abnormal spinal contour, but members deliberated whether the §4.71a 20% criterion of abnormal gait was adequately supported.  There was no question that abnormal gait was amply documented, although §4.71a stipulates “muscle spasm or guarding severe enough to result in an abnormal gait.”  Even though there was no direct evidence for spasm or guarding, members agreed that it would be overly speculative to conclude that it was not present; and,  even if the abnormal gait was more attributable to SIJ dysfunction, the latter was subsumed with the unfitting condition under consideration (as above).  Members thus agreed that reasonable doubt favored concession of antalgic gait as a ratable criterion, thereby supporting a 20% rating recommendation. 

There was no documentation of incapacitating episodes or diagnosis of intervertebral disc syndrome that would provide for a higher rating under that formula.  Members also considered whether separate rating could be recommended for the LLE radicular symptoms; but, given that the presence of radiating pain is subsumed under the §4.71a general spine formula, and that there were no objective motor or sensory deficits establishing a functional link to fitness, it was agreed that additional service rating could not be justified 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/left sacroiliac condition, proposing code 5237-5236.  

Contended Cervical Dysplasia and Spina Bifida Occulta Conditions.  The Board’s main charge was to assess the fairness of the PEB’s determination that neither of the above conditions were unfitting.  The CI was diagnosed with cervical dysplasia on a routine pap smear a few months prior to separation and was being monitored as per the standard of care.  Spina bifida occulta is a common congenital anomaly of the spine that was discovered as an incidental finding on X-ray.  Both conditions were asymptomatic, considered to meet retention standards, not profiled, and not implicated in the commander’s performance statement.

 There was no performance-based evidence that either of the above conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the cervical dysplasia and spina bifida occulta conditions; thus, neither is eligible for Service disability rating.  

BOARD FINDINGS:  In the matter of the lumbar condition (subsuming left SIJ dysfunction), the Board unanimously recommends a disability rating of 20%, coded 5237-5236 IAW VASRD §4.71a.  In the matter of the contended cervical dysplasia and spina bifida occulta 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Lumbosacral Strain with Left Sacroiliac Joint Dysfunction	5237-5236	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150618, 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

20 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002481 (PD201501459)

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