RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02258
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Health Care Specialist, medically separated for “low back pain” with a disability rating of 20%.

CI CONTENTION:  “PTSD was not rated, TBI from running over land mine not evaluated, lower back pain makes me unable to hold a job.”  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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 	VARD - 20051216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating Low Back Pain	5237	20%	Chronic Lumbosacral Strain with Osteoarthritis	5241	40%	20050608	
PTSD	Not Unfitting	Post-Traumatic Stress Disorder (PTSD)	9411	50%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Chronic Radiating Low Back Pain.  According to service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s condition began in Basic Training during hand-to-hand combat training.  The low back pain (LBP) continued and he was first seen on 30 April 2002, at which time he was treated with an injection of Toradol (ketorolac, a nonsteroidal anti-inflammatory drug (NSAID)), muscle relaxers, other NSAIDs, a temporary profile, and physical therapy.  Radiographic (X-ray) studies demonstrated a developmental variation of unilateral sacralization at L5, but were otherwise normal.  

During deployment on 27 August 2003, the CI had LBP, which was aggravated by a physical training test, with radiation into the left buttock.  Treatment for sacroiliac joint pain consisted of exercises, NSAIDs, and a temporary profile.  Subsequent episodes of LBP were treated with physical therapy and NSAIDs.   

Orthopedic evaluation in June 2004 noted the CI had left leg pain and numbness with running.  X-rays of the thoracic spine in July 2004 demonstrated minor scoliosis without other findings, while X-rays of the lumbar spine showed unilateral left sacralization of the fifth lumbar vertebra, with asymmetry of the sacral alae (widest parts of the sacrum) and sacroiliac joints and lumbar scoliosis.   There was no intervertebral disk space narrowing or other findings, but a bone scan revealed a small area of reactive bone formation in the left sacroiliac area.  X-rays confirmed the mild secondary reactive change from the developmental variant of articulation/segmentation.  A trial injection was carried out in August 2004 and an L5-S1 left-sided pseudo arthrosis (nonunion or false joint) steroid injection was performed on 30 August 2004; however, it did not completely take the LBP away and lasted for only 2 weeks.  As a result he could not run, do sit-ups, or carry a rucksack and a P3 profile was issued.  

At an orthopedic MEB consultation on 29 September 2004, 4 months prior to separation, the CI’s gait was normal.  He was able to forward flex with his hands to approximately 12 inches from the floor (approximately 75 degrees, normal 90) and had extension of 20 degrees (normal 30) and 25 degrees of both right and left lateral bending (normal 30).  He was able to walk on his heels and toes without difficulty and had no atrophy.  Neurologic evaluation was unremarkable.  The examiner indicated that the CI had greater than 2 years of non-operative management for his LBP from which he did not receive any significant relief, and he was not a surgical candidate.  

During the 5 October 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported LBP and paresthesias in the left thigh.  Physical examination showed tenderness to palpation of the left sacroiliac joint to the sciatic notch, but no spasm or deformity.  Straight leg raising (to determine nerve root irritation) was negative except the CI complained of pain in the left sacral area.  There was decreased sensation in the left lower extremity outer thigh to the medial shin.  Motor strength was normal.  Lumbar spine range of motion (ROM) measurements performed on 5 October 2004 used both a goniometer and inclinometer for forward flexion measurements, which were disparate and are in the chart below.  

The 13 December 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of constant low back pain aggravated by bending, lifting, twisting and impact activity.  Physical examination showed tenderness to pressure on the left at the sacroiliac junction down to the sciatic notch without palpable spasm or visible deformity.  Lumbar spine ROM measurements referred on OF 275, dated 5 October 2004, the results of which are in the chart below.  Neurological evaluation was unremarkable except for slightly decreased sensation in the left lower extremity along the outer thigh to the medial shin consistent with S1 nerve root dysfunction.  The CI was not able to lift and carry patients or heavy medical supplies.  

At the 8 June 2005 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported severe pain, but used no assistive devices.  He missed 2 days of work out of 60 days and had to leave work early on several occasions.  Flare-ups occurred with any prolonged running or standing or hard impact activities.  He also noted his left leg went numb if he stood on it for any length of time or if he attempted to drive or sit in a car for more than about 30 minutes.
When seated in a chair his lumbosacral area was flexed at approximately 90 degrees.  Physical examination revealed definite tenderness and paravertebral muscle spasms of a moderate degree.  ROM measurements are in the chart below.  Although the CI reported a sense of numbness in the left lower extremity to the knee, the examiner could not demonstrate a decrease in sensation to pain, pinprick, or light touch.  Muscle mass and strength in both lower extremities appeared to be excellent.  X-rays showed mild evolving osteoarthritis.  

The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	Ortho Consult MEB ~4 Mos. Pre-Sep
	MEB ~4 Mos. Pre-Sep and referenced by NARSUM ~2 Mos. Pre-Sep
	VA ~4 Mos. Post-Sep
	
Flexion (90 Normal)	“Approximately 12 inches from the floor or 75 degrees”	Lumbosacral measurements
(25)35, 32, 25*
	30, 25*	
Extension (30)	20	(15)20,20,15	15,5*	
R Lat Flex (30)	25	(30)30,30,30	20, 10*	
L Lat Flex (30)	25	(20)20, 20,20**	20, 10*	
R Rotation (30)	-	(30)40,40,40	25, 20*	
L Rotation (30)	-	(30)40,40, 40	25,20*	
Combined (240)	-	150	135,90*	
Comments		*Goniometer measurements; Inclinometer also used for forward flexion 40,40,48; **inclinometer used for lateral rotation-painful motion 	*Reduced due to pain after 5 repetitions IAW DeLuca; definite tenderness and paravertebral muscle spasms; when sitting in a chair, his lumbosacral area was flexed at approximately 90 degrees	
§4.71a Rating	-	(40%) PEB 20%	VA 40%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 20%, coded 5237 (lumbosacral strain), citing forward flexion 40 degrees.  The VA rated the LBP condition 40%, coded 5241 (spinal fusion), citing confirmation of chronic lumbosacral strain with osteoarthritis with painful and limited ROM of flexion to 30 degrees and a combined ROM to 135 degrees.  However, the VA also noted there was a likelihood of improvement, the assigned evaluation was not considered permanent and was subject to a future review examination in 5 years.

Members noted that forward flexion was 40 degrees as cited by the PEB was based on measurements performed with an inclinometer where the measurements were actually 40, 40 and 48 degrees, which more closely reflected the VASRD standard that requires thoracolumbar measurements.  Furthermore, the measurements performed with a goniometer were of lumbosacral motion rather than thoracolumbar motion.  Therefore, the measurements of 35, 32, and 25 degrees convert to approximately 65, 62, and 55 degrees of thoracolumbar motion.   However, prior to separation there were measurements performed by an orthopedic consultant to the MEB in which there was an approximation of flexion at 12 inches from the floor with the CI’s hands, which was interpreted as 75 degrees, but the examination did not include rotation measurements or address whether there was any or was not any painful motion.   

Members then discussed the VA ROM measurements performed 4 months after separation that were similar to the NARSUM measurements thereby raising an issue as to whether those VA ROM measurements were also lumbosacral rather than thoracolumbar especially in the absence of any reported accident, injury or surgery even though the VA used code 5241 for spinal fusion that referred to unilateral sacralization of the fifth lumbar vertebra rather than a surgical fusion.  Nevertheless, the panel members were aware that there was definite back tenderness and paravertebral muscle spasms that were not previously noted in prior examinations, which could account for the 30 degrees flexion measurement, although the etiology of the tenderness and spasms after separation were not clear.  However, members concluded that of the several measurements proximate to separation, those performed by the orthopedic consultant, were most consistent with the CI’s clinical and imaging findings.  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 radiating low back pain condition.  

Contended PEB Condition:  PTSD.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  The CI was CI was seen on 19 July 2004 requesting anger/stress one-on-one screening because he was irritable with his girlfriend.  He was referred to mental health for further evaluation and was prescribed Ambien (zolpidem, a sedative) for sleep, which he took only two or three times.  

At a mental health MEB consultation on 3 November 2004, the CI reported trouble sleeping with dreams related to his deployment because of mortar attacks and when he was in a vehicle as a passenger that ran over a land mine in November 2003.  He was not injured, but the vehicle was destroyed.  On mental status examination he was alert, oriented, cooperative, and neatly groomed.  Eye contact was good and speech was of normal rate and rhythm and he had a good sense of humor.  No abnormal motor movements were present.  Mood was euthymic and affect was appropriate.  He denied suicidal and homicidal ideation, hallucinations or delusions.  Concentration was intact as was abstracting ability.  Intellect was average and memory, insight, and judgment were intact.  The CI was assessed as experiencing symptoms of posttraumatic stress disorder and his symptoms interfered with his social life, but there was a minimal effect on his job performance.  The CI showed motivation to obtain treatment and was open to the idea of eye movement desensitization and reprocessing (EMDR).  His Axis I diagnosis was posttraumatic stress disorder chronic, mild and his Global Assessment of Functioning score was 70 (some mild symptoms or some difficulty in social, occupation, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships).  The examiner considered the Axis I psychiatric condition was not unfitting for military duty at that time and there was no psychiatric profile.  

The CI was to follow-up for EMDR treatment, take Ambien as needed, and follow-up with the VA after separation as needed.  There was no performance-based evidence from the record that the condition 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 the contended condition; and so, no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic 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 contended PTSD condition, the panel unanimously recommends no change from the PEB determination 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150826, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012862, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

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,