RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01585
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Unit Supply Specialist, medically separated for “chronic low back pain,” with a disability rating of 0%.  

CI CONTENTION:  “Consider all conditions.”  The 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 or non-compensable.  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 determination 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(s) 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 - 20060308	VARD - 20060414	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	0%	Lumbago	5237	0%	20050923	
Seasonal Allergies	Not Unfitting	Allergic Rhinitis	6522	0%	20050923	
Left Forearm Muscle Tear		Olecranon Bone Spur With Muscle Tear, Left Forearm	5399-5308	0%	20050923	
Neck Pain		Cervical Neck Condition	5237	NSC	20050923	
Anxiety Disorder		Anxiety Disorder	Deferred	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain condition began in approximately 1997 (during prior service) after a car accident.  On 28 April 2005, the CI reported he had stiffness “doing PT” and “pain varied with activity.”  He also noted he had been told he had degenerative disc disease (DDD) at L4-5.  Treatment consisted of Mobic (meloxicam, a nonsteroidal anti-inflammatory drug (NSAID)) and physical therapy.  X-rays of the lumbar spine were normal.  The CI had numerous chiropractic and physical therapy treatments in 2005 with only mild and temporary pain relief.  At an orthopedic clinic visit on 26 August 2005, he noted lower back pain for 9 years and had difficulty wearing IBA (individual body armor) and performing excessive physical activity.  He described the pain as sharp and denied any loss of bowel or bladder function, weight loss, paresthesias, tingling or sensation changes.  On examination there was very mild tenderness on palpation of the lumbosacral spine on L1/L2, but no muscle spasm.  His range of motion (ROM) was full with no pain on motion.  Straight leg raising (to determine nerve root irritation) was negative.  X-rays of the thoracic spine showed the vertebral bodies to be normal in appearance and the intervertebral disc spaces were maintained.  There was no evidence of traumatic or significant arthritic changes.  Very mild levoscoliosis (spinal curvature to the left) was also noted.  The CI was advised he was not a surgical candidate.  

Despite treatment, the back 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 “chronic low back pain” for PEB adjudication.  

The 8 February 2006 MEB NARSUM examination, 1 month prior to separation, noted complaints of pain and tightness in his lower back, which were precipitated by physical activity.  Physical examination showed a full ROM, both active and passive with flexion 90 degrees (normal 90), extension 30 degrees (normal 30), both right and left lateral flexion 30 degrees (normal 30), and both right and left rotation 30 degrees (normal 30).  He had a negative straight leg raising bilaterally and a normal heel-to-toe walk.  He did not display any related muscle atrophy.  His strength was normal at 5/5, and he had normal sensation and lower extremity reflexes.  

At the 23 September 2005 VA Compensation and Pension (C&P) evaluation, 6 months before separation, the CI reported pain and tightness in his lower back.  Physical examination showed a normal posture and gait.  The lumbar spine was normal in appearance and was nontender to palpation.  There was no muscle spasm present and he had negative straight leg raising testing.  Thoracolumbar ROM measurements showed active flexion to 90 degrees, extension 30 degrees, right and left lateral flexion both 30 degrees, and right and left  rotation both 30 degrees and a combined ROM 240 degrees (normal 240) after repetitive motion.  The examiner noted no pain, weakness, fatigue or incoordination following repetitive motion, and there was no palpable swelling, joint effusion or tenderness.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 0%, coded 5299-5237 (Lumbosacral strain), citing a combined thoracolumbar ROM of 240 degrees and without neurologic abnormality.  The VA also rated the chronic low back pain condition 0% coded 5237, citing X-ray findings that demonstrated a normal lumbar spine and physical examination showed a full ROM of the spine with no clinical findings such as painful motion, tenderness, instability, crepitus, neurological deficit, functional limitation and no limitation noted with repetitive use.  

The panel agreed there was no limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine and the MEB and VA C&P examinations did not note the presence of painful motion, muscle spasm, guarding or localized tenderness.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height nor was there evidence of additional functional loss that would impact functioning in the average civil occupation.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).   

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 low back pain condition.  

Contended Conditions-Seasonal Allergies, Left Forearm Muscle Tear, Neck Pain, and Anxiety Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions except the seasonal allergies were profiled or implicated in the commander’s statement or judged to fail retention standards.  All conditions were medically acceptable.  

Seasonal Allergies.  Allergy testing on 1 June 2004 revealed the CI had multiple positive responses to skin tests for trees, grasses , ragweed, and several pets.  Treatment consisted of immunotherapy (“allergy shots”).  In April 2005 the CI had profuse clear rhinorrhea (“running nose”) and was treated with antihistamines (fexofenadine and chlorpheniramine) and Flonase (fluticasone, a steroid) nasal spray.  In July 2005 the CI complained of allergies and dyspnea (shortness of breath).  Evaluation was unremarkable and he was referred for allergy shots.   A P2 profile for severe seasonal allergic rhinitis dated 31 August 2005 indicated the CI could not perform physical training on grass.  The MEB NARSUM indicated the condition did not affect the CI’s deployability.  

Left Forearm Muscle Tear.  In April 2003 the CI reported left forearm swelling with a muscle defect after lifting weights 2 weeks earlier.  Magnetic resonance imaging (MRI) in August 2003 revealed no abnormal signal in the left wrist in the area of the distal brachioradialis muscle.  In October 2005 the CI was evaluated for the left forearm muscle tear that occurred in 2003.   On examination there was no tenderness to palpation of the forearm; there was a full ROM of the forearm; and there was step-off displacement along the body of the radius.  The soft tissue defect identified on physical examination was not identified by MRI evaluation and the structures of the forearm appeared normal.  In November 2005 the CI desired surgical intervention and had one session of occupational therapy where a deformity was noted along the extensor wad (a group of three muscles of the posterior compartment) of his left forearm and his average grip strength on the left was 70 pounds and on the right 93 pounds.  Orthopedic evaluation on 4 November 2005 was completely normal and there were no surgical or activity recommendations.  The NARSUM noted the CI reported symptoms of tingling and a burning sensation when he stress the muscle.  At the VA examination a small bone spur was noted on X-ray along the dorsal aspect of the wrist and physical examination noted a small nontender mass of the left forearm, which was consistent with a muscle rupture/tear.  

Neck Pain.  The CI complained of pain of the left neck and chest in August 2004 after lifting weights and his motorcycle.  Treatment consisted of Naprosyn (naproxen, an NSAID), Flexeril (cyclobenzaprine, a muscle relaxer), and physical therapy.  In February 2006 the CI awakened with right neck pain and limited ROM.  Spasm in the right trapezius muscle was treated with cyclobenzaprine, a muscle relaxer.  The NARSUM indicated the CI’s very infrequent symptoms were relieved by heat, massage, and stretching exercises.   

Anxiety Disorder.  The CI reported chest pain in February 2006 secondary to stress of doing the medical Board.  His symptoms, which resolved after resting in the Emergency Department, were felt to be most likely secondary to anxiety and he was started on Xanax (alprazolam).  The NARSUM indicated the CI was under treatment by Behavioral Health and was taking Zoloft (sertraline, an antidepressant medication).  

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 chronic low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended seasonal allergies, left forearm muscle tear, neck pain, and anxiety disorder conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  

The panel, 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 20150625, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008547, 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