RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01860
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050511

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Petroleum Supply Specialist, medically separated for “chronic non-radiating low back pain [LBP]” and “pain and stiffness of left great toe,” rated at 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “Review 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 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 - 20050304	VARD – 20050713	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Non-radiating LBP	5299-5237	10%	Lumbosacral Strain	5237	10%	20050622	
Pain and Stiffness of Left Great Toe	5281	10%	Left Foot Strain, Status Post Fusion, First MTPJ	5284	10%		
Mild Subacromial Impingement of the Left Shoulder	Not Unfitting	Rotator Cuff Tear with Recurrent Subluxation, Left Shoulder	5201	20%		
Sleep Maintenance and Sleep Onset Insomnia		Sleep Apnea	6847	NSC	STR	
Habitual Snoring						
Status Post GI Bleed		No VA Placement	
Right Hip Pain		Status Post Avulsion Fragment, Posterior Superior Right Hip Joint	5252-5010	10%	20050622	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Non-Radiating Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported the onset of LBP during basic training.  No trauma was noted nor was there improvement with initial treatment.  An X-ray on 30 May 2002 was essentially normal.  Over the next year, he was treated with duty modifications and medications without significant improvement.  On 20 May 2003, an MRI showed degenerative disc disease (DDD) at L4-5 and L5-S1.  In physical therapy on 2 June 2003, the gait and range of motion (ROM) were normal.  The neurological examination was intact.  In physical medicine on 12 September 2003, the ROM was near normal but painful.  The neurological examination remained normal.  A bone scan on 17 September 2003 showed mild increased uptake in the sacroiliac joints, the joints between the spine and pelvis.  He was treated with a steroid injection with some benefit.  In a total joint clinic on 13 May 2004, 12 months prior to separation, he was noted to have full active ROM.  The gait and neurological examination were normal.  Full functional ROM was noted in physical therapy on 12 July 2004.  A repeat MRI on 28 September 2004 noted DDD at L3-4, L4-5, and L5-S1.  The CI was unable to return to full duty despite treatment and entered into the MEB process.  

At the 21 September 2004 MEB examination (recorded on DD Forms 2807 and 2808), 7 months prior to separation, the CI reported constant LBP.  On examination, the neurological examination was normal and provocative testing for nerve root irritation was negative.  At the 2 November 2004 MEB NARSUM examination, 6 months prior to separation, the CI reported LBP since advanced infantry training.  The CI reported the LBP was progressing despite treatment.  On examination, provocative testing for nerve root irritation remained negative.  Minimal tenderness was present.  The gait was normal other than as limited by a boot for his foot (below).  The ROM was noted to be good and with minimal pain.  The neurological examination was normal.  The panel noted that the examination cited mirrored that from orthopedics dated 13 October 2004.  The MEB forwarded mechanical low back pain for PEB adjudication.  

At the 22 June 2005 VA Compensation and Pension (C&P) evaluation, 6 weeks after separation, the CI reported ongoing LBP, but denied incapacitation.  He did report flexion limited to 45 degrees with flares, but the frequency of these was not recorded.  On examination, spasm was present as was tenderness.  Flexion was limited to 80 degrees (normal 90) and the combined ROM was 225 (normal 240).  The neurological examination was normal and atrophy was absent.  No abnormal curvature was present.  The gait and station were normal.  The panel noted that the VA accomplished a second C&P examination on 24 January 2006, over 8 months after separation.  Posture and gait remained normal.  Spasm and tenderness were absent.  The neurological examination remained normal.  Flexion was reduced by pain to 45 degrees and the combined ROM was reduced to 140 degrees (after rounding).  The panel noted that this is a significant limitation compared to all previous examinations.  Also that the ROM is worse on this C&P, which was without tenderness and spasm, than on the previous C&P which noted the presence of both tenderness and spasm.  No recent injury was documented which could account for this deterioration.  These values are also less than would be expected with a normal gait and posture.  The probative value of this examination is accordingly reduced and it is not used for rating purposes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 10%, coded 5299-5237 (analogous to lumbosacral strain), noting tenderness on examination.  The VA also rated the back at 10% and used the 5237 code, noting painful and limited motion.  The evidence does not support the presence of an unfitting radiculopathy at separation.  The gait was typically normal.  The ROM was typically noted to normal or slightly reduced.  Painful motion was present.  Incapacitation was denied.  The Board found no route to a rating higher than the 10% adjudicated by both the PEB and VA proximate to separation.  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 non-radiating low back pain condition.  

Pain and Stiffness of Left Great Toe.  According to the STR and the MEB NARSUM, the CI had X-rays for bilateral foot pain on 25 July 2001 which showed minimal loss of the plantar arches.  The CI was seen periodically over the next few years for persistent foot pain.  Despite conservative management including orthotics (shoe inserts), his pain persisted and surgery of the left great toe with lengthening of a calf muscle was performed on 14 November 2003.  Following surgery, the CI had some improvement, but did not have resolution of his symptoms and continued limited duty.  He continued the use of custom orthotics.  A bone scan and CT scan were consistent with arthritic changes.  He was issued an orthopedic boot, but had persistent pain.  Fusion of the joint was recommended and accomplished on 1 June 2004.  At a podiatry follow up on 26 August 2004, it was noted that he had ongoing pain.  On examination, the fused toe was immobile (as expected), but painful.  He was then seen on 14 October 2004 and reported that he could only wear regular shoes about 1 hour before it was too painful to continue wearing them.  On examination, the joint was fused and aligned with the ray of the toe.  Moderate flat feet were observed.  Strength was normal.  He was thought to be stable, but his prognosis was poor if he continued military duties.   

The MEB NARSUM examination noted the use of an orthopedic boot.  This precluded toe and heel walking.  However, his gait was otherwise normal and strength intact.  Sensation was normal.  The MEB forwarded chronic painful left first metatarsophalangeal joint for PEB adjudication.  

At the 22 June 2005 VA C&P evaluation the CI reported no limitations in daily activities or working from the toe condition.  On examination, the left great toe was noted to be fused in a neutral position.  Tenderness was present.  The scar was well healed and swelling absent.  Flat feet were not clinically evident.  The second C&P noted a normal gait.  The toe and scar were tender on examination.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the pain and stiffness of the left great toe at 10%, coded 5281 (hallux rigidus).  The VA also rated the toe condition at 10%, but coded it 5284 (other foot injuries).  The panel considered the evidence.  It showed that the CI had a good outcome from the fusion although he remained symptomatic.  He was limited in how long he could wear a normal shoe, but displayed a normal gait and strength on multiple examinations.  The panel found no route to a rating higher than the 10% adjudicated by the PEB and VA.  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 left great toe condition.  

Contended PEB Conditions:  Mild Subacromial Impingement of the Left Shoulder, Sleep Maintenance and Sleep onset Insomnia, Habitual Snoring, Status Post Gastrointestinal Bleed, and Right Hip Pain.  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 were profiled.  The shoulder condition was implicated in the commander’s statement, but specific limitations were not cited.  All five conditions were judged to meet 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 chronic non-radiating low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the pain and stiffness of the left great toe condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended mild subacromial impingement of the left shoulder, sleep maintenance and sleep onset insomnia, habitual snoring, status post gastrointestinal bleed, and right hip pain 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 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 20150708, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009222, 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