RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01650
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20021019

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, UH-60 Helicopter Repairer, medically separated for “chronic low back pain…” with a disability rating of 10%.

CI CONTENTION:  The CI requested a review of 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 - 20020809	VARD - 20021026	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5295	10%	Mechanical Low Back Pain	5295	10%	STR	
Chronic Left Elbow/Arm Pain	Not Unfitting	Left Lateral Epicondylitis ...	8599-8516	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a chronic history of atraumatic low back pain that began to worsen in September 2001.  Multiple STR clinical entries confirmed the absence of radicular symptoms and normal neurological findings (5/5 strength), with no contrary evidence.  Lumbar X-rays were normal (no other imaging in evidence).  There were serial physical therapy (PT) entries that graphically charted the progress of thoracolumbar range of motion (ROM) in all planes.  These documented moderate limitations initially (~50% reduction in extension, ~25% reduction in flexion, and 0-40% reductions in bilateral flexion and rotation) that improved to near normal (~25% reduction in extension, normal flexion, and minimal to no reduction in bilateral flexion and rotation) by January 2002.  A primary care entry in April 2002 (2 weeks before the measured ROM per the orthopedic addendum to the NARSUM that follows) described grossly normal ROM.  There were no STR entries that indicated more severe ROM limitation.  There were no STR entries that documented abnormalities of gait or posture and none that documented incapacitating flares of back pain.  There was no surgical indication; conservative treatment did not result in improvement sufficient to allow unrestricted duty; and, the CI was referred for MEB.  

The 17 July 2002 NARSUM was not itself probative for rating the lumbar condition, and deferred to an orthopedic addendum of 3 May 2002 (5 months before separation).  Neither of these examiners (or other STR source) documented any interim injury or exacerbation of the condition.  The MEB orthopedist documented constant back rated 5/10 (without radicular complaints) that was exacerbated by running, jumping, and load-bearing.  The physical examination recorded tenderness without note of spasm and normal neurological findings (5/5 strength, intact sensation, symmetric reflexes).  Measured ROM was flexion to 30 degrees (normal 90), extension to 10 degrees (normal 30), and bilateral flexion to 30 degrees (normal 30).  There were no measurements of rotation for calculation of combined ROM, and no comments with regard to painful motion or guarding.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The 2002 VASRD coding and rating standards for the spine, which must be applied to the panel’s recommendation IAW DoDI 6040.44, differed significantly from the current §4.71a general rating formula for the spine.  The PEB rated the low back pain condition 10%, coded analogously under the older code as 5295 (lumbosacral strain) citing “pain on forward motion” that was consistent with the 10% criterion of the “characteristic pain on motion” of code 5295.  The VA rated the low back pain condition 10%, under the same code and based on the same evidence, citing reduced ROM and spinal tenderness.  

None of the criteria for a higher rating under code 5295 were in evidence.  The older code 5293 (intervertebral disc syndrome) was neither clinically applicable nor favorable given the absence of evidence for “recurring attacks” requisite for a higher rating.  The only remaining code available in the 2002 VASRD subject to consideration was code 5292 (limitation of motion); and,  the panel considered a higher rating under that code based on its 20% criterion of “moderate” or 40% criterion of “severe” limitation.  

Members noted that the ROM evidence from the orthopedic addendum, especially the very limited flexion to 30 degrees, would justify a higher rating under code 5292 if it were judged sufficiently probative.  There was, however, ample contrary evidence (especially the fairly specific PT evaluations) that indicated ROM had normalized over time; and, there was no explanation for the deterioration in ROM that was confined to the single set of MEB measurements.  No evidence over a long stable clinical course corroborated the presence of severe ROM limitation, especially approaching separation; nor, was severe ROM limitation clinically congruent with the pathology (apparent myofascial strain without evidence of disc disease).  Further considering that there was no corroboration of the associated spasm and guarding that would logically accompany the ROM measurements reported in the orthopedic addendum, members agreed that this evidence was insufficiently probative as the sole support for a higher rating recommendation under code 5292.  There was no evidence in support of additional rating for spinal neuropathy.  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 of the low back pain condition.

Contended PEB Condition: Left Elbow/Arm Pain.  The CI reported an onset of left (non-dominant) upper extremity (LUE) pain with intermittent paresthesias in September 2001 after the MEB for the back was initiated.  The only STR clinical entries for the condition addressed it as a collateral complaint with the back, and there was no evidence of any ancillary work-up (imaging, nerve study, etc.).  The orthopedic addendum to the NARSUM noted difficulty with “prolonged double flexion” (exampling turning a door knob) as the only documented functional limitation.  The neurological examination recorded 5/5 LUE strength, but a “mild blunting of sensation” in the left ulnar nerve distribution.  The MEB orthopedist diagnosed “epicondylitis [bone inflammation] with secondary ulnar neuralgia” which was judged to meet Army retention standards.  Although the profile was for “chronic back and arm pain,” it was U1 (L3).  The commander’s performance statement did not document any arm condition or upper extremity limitations.

The panel directed attention to its recommendation based on the above evidence, and its main charge was an assessment of the fairness of the PEB’s determination that the LUE condition was not unfitting. The panel’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Members agreed that there was insufficient performance-based evidence that indicated the condition interfered with duty requirements to an extent that would have prohibited further military service.  After due deliberation in consideration of the preponderance of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the left arm condition; thus, it was not eligible for rating.

BOARD FINDINGS:  In the matter of the 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 left arm condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150620, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008780, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	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