RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01507
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040816

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

CI CONTENTION:  “Please consider all conditions.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’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 panel 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 panel 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 – 20040522	VARD - 20040817	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP following Back Strain, with Finding of Degenerative Disc Disease (DDD), with Small Protrusion at L5/S1 without Radiculopathy	5237	10%	Low Back Strain	5237	10%	STR	
Residual Cold Intolerance and Foot Paresthesias	Not Unfitting	No VA Placement 	
Gastroesophageal Reflux	Not Unfitting		
Headaches	Not Unfitting		
Insomnia	Not Unfitting		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

LBP.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his back in 1999 while lifting heavy objects during advanced individual training.  The 5 June 2002 lumbar spine X-rays showed mild scoliosis (abnormal lateral spine curvature) and mild L5/S1 disc space narrowing.  The 2 October 2003 lumbosacral spine X-rays showed possible L5/S1 intervertebral disc degeneration.  The 28 October 2003 lumbar spine diagnostic imaging (MRI) studies showed very mild lumbar spondylosis (spine degenerative disease) and a small L5/S1 disc protrusion which caused no stenosis (narrowing).  The 20 February 2004 clinic encounter physical examination documented a gait that was not antalgic.  The back and hip examination revealed no spasm, deformity, step-off, sacroiliac joint tenderness, or greater trochanter (proximal lateral femur bony prominence) tenderness.  Spine range of motion (ROM) was flexion of 90 (normal), extension of 10 (normal 30), bilateral lateral flexion of 30 (normal), full bilateral rotation, and combined of 220 (normal 240) degrees.  The straight leg raise (SLR), a test to assess for herniated disc causing sciatic nerve root [L5/S1] radiculopathy) and Patrick (assesses hip and SI joint pathology) tests were negative.  Strength and deep tendon reflexes (DTRs) were normal.  The diagnosis listed chronic mechanical LBP.  

During the 1 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported paresthesias in the low back and left lower extremity  sometimes to the foot along with near daily headaches. Physical examination of the lumbar spine revealed mild lumbosacral junction tenderness with no spasm or deformity.  There was pain-limited spine ROM at flexion of 70 (normal 90), extension of 20 (normal 30), and combined ROM of 195 (normal 240) degrees.  The SLR tests were negative.  Strength, DTRs, and sensation were normal except for slight decreased sensation in the bilateral feet and toes (left greater than right).  On 3 May 2004 physical therapy (PT) measured ROM for the MEB with a goniometer.  Pain-limited lumbar spine ROM repeated three times was flexion of 70/78/76, extension of 20/20/15, right lateral flexion of 25/18/13 (normal 30), left lateral flexion of 30/28/25 (normal 30), right rotation of 20/15/15 (normal 30), and left rotation of 30/20/20 (normal 30), and average combined of 205 degrees.  

In the 4 May 2004 MEB NARSUM, 3 months before separation, the CI complained of constant LBP with intermittent radiation down the left lower extremity.  Symptoms were exacerbated by prolonged standing (greater than 1 hour), running, bending, lifting, twisting, and impact activities.  He did not experience significant improvement from conservative management (activity modification, PT, chiropractic manipulation, medication).  The examiner cited the PT ROM for the MEB.  The lumbar spine examination revealed mild lumbosacral junction tenderness with no spasm or deformity.  Pain-limited spine ROM was flexion of 80 (normal 90), extension of 20 (normal 30), and combined of 200 (normal 240) degrees.  The SLR tests were negative.  Strength, DTRs, and sensation were normal except for slight decreased sensation in the bilateral feet and toes (left greater than right).  There was no sign of radicular (nerve root) sensory loss.  The examiner recounted the findings of the X-rays and MRI.  The diagnosis listed chronic LBP with DDD.  There was no VA examination in evidence within the 12-month allowable window for adjudication.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (lumbosacral strain) citing chronic LBP, intermittent left leg pain, DDD, small L5/S1 disc protrusion, tenderness, ROM, and no radiculopathy.  The VA assigned 10% rating under the 5237 code (lumbosacral strain).  The panel 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) as reported on the MEB NARSUM examination proximate to separation.  

The panel also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had reported intermittent pain down the left lower extremity, however, examinations indicated normal strength, reflexes and gait, and the sensory changes did not affect his job.  The presence of functional impairment with a direct impact on fitness is the key determinant in the panel’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 panel 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 panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic LBP condition. 

Contended PEB Conditions: Residual Cold Intolerance and Foot Paresthesias, Gastroesophageal Reflux, Headaches, and Insomnia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The cold weather injury was profiled, but the profile did not limit any performance of duties.  The remaining conditions were not profiled.  None of the conditions were 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 panel 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 low back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended residual cold intolerance and foot paresthesias, gastroesophageal reflux, headaches, and insomnia conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends 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 20150619, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009045, 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