RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00121
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070827

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Military Police, medically separated for “lumbosacral strain” with a 20% disability rating.  

CI CONTENTION:  The CI contended that his disability rating should be higher for his unfitting condition.  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 - 20070716	VARD - 20080311	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	20%	Lumbosacral Strain and DDD 	5243	40%	20080118	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed an atraumatic onset of back pain during training in April 2001 that was aggravated by a 2005 deployment to Iraq (completed tour).  The pain persisted upon redeployment and was associated with bilateral lower extremity (BLE) radiation and sensory symptoms.  Imaging (MRI) demonstrated degenerative disc disease (“minimally diffuse” bulge without nerve encroachment at L3/4).  Electrodiagnostic testing reported “chronic active right L4/5 radiculopathy,” but a discogram did not identify surgical indications.  There were multiple STR clinical entries that documented normal neurological examinations, with none to the contrary, and orthopedics opined that the CI was not a surgical candidate.

There were some STR clinical entries that documented grossly normal range of motion (ROM), although most indicated nonspecific ROM limitation.  One early physical therapy (PT) entry characterized ROM as “significantly limited,” and the MEB’s DD Form 2808 physical examination (3 months before separation) documented “very limited forward flexion.”  There was intermittent STR documentation of an antalgic gait, although this was not consistent, and ample STR documentation of a normal spinal contour.  There was no STR documentation of any incapacitating episodes.  

The 22 May 2007 NARSUM examination, 3 months prior to separation, documented persistent back pain with BLE radiation rated “7/10 at rest and becomes 10/10 with increasing activity.”  With regard to functional limitations, the NARSUM noted an inability to meet most general soldiering requirements, and the commander’s performance statement added that the CI was “prevented from standing and working for long periods of time.”  The physical examination recorded an abnormal gait due to spasm and guarding, a normal spinal contour, and referenced normal neurological findings.  The NARSUM cited goniometric ROM measurements performed by PT a month earlier (26 April 2007): average flexion to 40 degrees (normal 90) with a combined ROM of 150 degrees (normal 240), specifying limitation by pain and recording three measurements for each plane.
  
The 18 January 2008 VA Compensation and Pension (C&P) orthopedic examination, 5 months after separation, did not document any interim injury or other exacerbation of the condition.  The CI reported daily “excruciating” back pain with bilateral radicular symptoms (not elaborated) that he rated 10/10, stating that it limited walking “to 10 minutes on good days” and rendered him “totally nonfunctional because of the pain.”  The examiner stated that there had been no incapacitating episodes.  The physical examination recorded an antalgic gait, although a general C&P examiner on the same day noted a normal gait.  The orthopedic examiner recorded tenderness, but no spasm or abnormal contour, and normal neurological findings.  The VA ROM measurements portrayed severely limited ROM, noting only one value for each plane, and stating that the CI could not tolerate repetitions.  The reported measurements were forward flexion to 5 degrees, 5 degrees each for right and left flexion and rotation, and “none” for extension.  This yielded a combined ROM of 25 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 20% rating under code 5237 (lumbar spine strain) was consistent with VASRD §4.71a spine criteria for the service ROM and other ratable evidence.  The PEB addressed the radiculopathy as not separately ratable because of normal objective neurological findings.  The VA‘s 40% rating under code 5243 (intervertebral disc syndrome) was based on the C&P evidence and justified by “the extent of limited motion.”  The decision specified that the radiculopathies were not ratable.

There was a great disparity between the service and VA evidence with clear implications for the panel's rating recommendation; and, members deliberated the probative value of the conflicting evaluations, with review of the overall evidence for corroboration.  Members agreed that the service evidence carried the determinant probative value for the following reasons.  

The service ROM evidence was corroborated by multiple STR entries over an extended stable course.  No service examiner documented ROM limitation approaching the severity of that reflected by the VA measurements.  

The VA ROM measurements were not well aligned with the collateral physical findings.  The absence of spasm with a normal spinal contour, and the conflicting gait observations by different VA examiners on the same day, were difficult to clinically reconcile with the magnitude of ROM limitation reflected by the measurements.  

The quality of the service PT ROM evaluation was superior.  The VA examiner recorded a single measurement in each plane of motion, with no indication that further ROM was attempted after the onset of pain; whereas, the service PT examiner provided serial measurements in each plane.  This was quite suggestive that the measured ROM end-points by the VA examiner were determined by subjectively reported pain thresholds rather than by ratable spine immobility.  

Finally, the service evidence was better aligned with the clinical picture.  The extraordinarily severe ROM limitation reflected by the VA measurements was not consistent with the pathology (mild non-surgical DDD); and, the abrupt deterioration in ROM at the time of the VA examination, preceded by a lengthy stable course and with no history of any re-injury or other exacerbation, was not clinically logical.

Having assigned the determinant probative value to the service ROM evidence that supported a §4.71a rating of 20%, and noting that there was no documentation of incapacitating episodes that would provide for a higher rating under that formula, members considered whether additional service rating was justified for peripheral nerve impairment due to radiculopathy.  The presence of functional impairment with a direct impact on fitness is the key determinant in the panel’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from nerve involvement, that is subsumed under the VASRD §4.71a general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Since there was no objective evidence of sensory impairment or motor weakness that would have logically impacted military occupation-specific activities, members concluded that additional rating was not justified on this basis.

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 lumbar spine condition.

BOARD FINDINGS:  In the matter of the lumbar spine condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  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 20160308, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013364, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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