RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01638
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20091016

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Basic Trainee, medically for “T12-L1 compression fracture” with a disability rating of 20%.

CI CONTENTION:  “Chronic back pain, self-medicated with 400 mg Ibuprofen daily.”  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 upon a 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 – 20090928	VARD - 20100626	
Condition	Code	Rating	Condition	Code	Rating	Exam	
T12-L1 Compression Fracture	5235	20%	L1 Vertebral Compression Fracture	5235	0%	20100128	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

T12-L1 Compression Fracture.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s compression fracture resulted from an obstacle course fall on 30 March 2009.  MRI (magnetic resonance imaging), X-ray and CT (computed axial tomography) scan studies were positive for disc height loss at T12-L1.  Studies were negative for spinal nerve compression (nerves leave the spinal canal through the foramen (opening between vertebra and exits to other parts of the body)); as well as disc budging and herniation.  No electro-diagnostic studies were conducted.  An orthopedic examination determined the CI suffered no neurovascular compromise; therefore, she was treated conservatively with a back brace, pain medication and physical therapy; surgery was not indicated.  At a physical therapy examination dated 15 April 2009 (6 months pre-separation), the CI reported nightly sharp-intense repositioning pain and daily-achy pain, which could radiate up and down her back.  Gait and muscle spasms were not cited, but she was positive for tenderness at thoracic-lumbar paraspinal.  Her posture was obstructed by a back brace.  Lumbosacral range-of-motions (ROM) revealed forward flexion to at least 90 degrees (90 normal).  During two consecutive orthopedic examinations on 4 May 2009 and 14 July 2009 (3 months pre-separation), the CI reported intermittent back pain and numbness over her right thigh.  Muscle spasm and radiating lower back pain were negative, but tenderness at the L1 region was present.  The lumbosacral ROM flexion was to 80 degrees and was painful.

The commander’s performance statement dated 15 July 2009 did not implicate the CI’s back condition or incapacitating episodes.  During a physical examination performed on 27 July 2009 the CI reported right paraspinal region tenderness.  Neurological testing was normal.  On the same date, a physical therapist performed MEB ROM testing.  Localized spinal tenderness, muscle spasm, guarding were present while spinal contour was within normal limits.  The thoracolumbar ROM measurement of flexion at 59 degrees with pain which increased to 75 degrees after three repetitions.

The MEB narrative summary examination was performed on 05 August 2009.  The examination was within normal limits referencing the previous 27 July 2009 physical therapy examination.  The examiner opined, the CI would continue to have back pain aggravated by prolonged sitting and standing with flare-ups that would limit her bending [forward flexion] and ability to lift for years to come.  A physical therapy examination dated 18 September 2009 (1 month pre-separation) also performed MEB ROM testing.  Localized spinal tenderness and guarding were present.  Muscle spasm was absent while spinal contour was within normal limits.  Goniometric thoracolumbar ROM measured flexion at 50 degrees with pain which increased to 64 degrees after three repetitions.

During the VA Compensation and Pension (C&P) dated 28 January 2010 (3 months after separation), the CI reported lower-mid back pain with flares with daily activity.  Her back brace was no longer worn.  Her examination was normal.  She had not worked since leaving the service; therefore, incapacitation or missed work could not be assessed.  

The Board directed attention to its rating recommendation based on the above evidence.   The PEB assigned a 20% rating under the 5235 code (vertebral fracture), citing limitation of forward flexion.  The VA assigned a 0% rating also using the 5235 code based on the VA C&P examination 3 months after separation, citing non-compensable limitation of motion.  The Board noted the last two PT ROM values charted above initially supported a 20% rating for limitation in motion; however, after three repetitive motions only supported a 10% rating.  Although there was muscle spasm and guarding, they were not severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  Additionally, there was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula. The Board then considered whether an additional Service rating could be recommended under a peripheral nerve code.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.

The Board concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB; and, DoDI 6040.44 4.e. (4) states:  “No reduction of the previously issued combined disability rating will result as a product of this review.”  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 T12-L1 compression fracture.

BOARD FINDINGS:  In the matter of the T12-L1 compression fracture 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 20150618, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160015993 (PD201501638)

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