RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00419
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20030102

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, O4, Chemical Munitions Material Management Officer, medically separated for low back pain, with a disability rating of 10%.   

CI CONTENTION:  The CI contends for 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 - 20020924	VARD - 20030924	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain with Pain on Motion	5299-5295	10%	Intervertebral Disc Syndrome of the Lumbar Spine 	5293-5295	0%	20030707	
Chronic Intermittent Gout	Not Unfitting	Gout Involving the Knees and Ankles	5017	20%	20030707	
Bilateral Knee Medial
Degenerative Joint Disease	Not Unfitting					
Central Serous Retinopathy	Not Unfitting	Central Serous Retinopathy	6099-6079	0%	20030707	
Hailey-Hailey	Not Unfitting	Hailey-Hailey Rash	7815	0%	20030707	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 1992 without any specific injury or trauma.  A lumbar spine series in September 2001 showed mild degenerative disc disease at L1-L2 with small osteophyte formation at L1-L2.  A chiropractic note dated 5 September 2001 indicated the CI had pain radiating into the right leg.  
The CI felt good for a day or two after treatment.  In January 2002 the CI slipped on ice and had severe muscle spasm, which was treated with Tylenol #3 (acetaminophen, a pain reliever, and codeine, a narcotic), a nonsteroidal anti-inflammatory drug (NSAID), and a muscle relaxer.  At a chiropractic evaluation in April 2002, the CI had within normal flexion and painful extension.  Magnetic resonance imaging (MRI) in 28 May 2002 showed degenerative changes at L1-L2, L4-L5 and L5-S1 with mild broad bulges at the latter two levels without evidence of spinal stenosis or neural foraminal narrowing.  In June 2002 the CI was advised not to wear his back brace unless of an acute exacerbation of pain, and then, only for a few days.  Back pain increased as a result of having to wear a rucksack and flak vest.  He was no longer able to do sit-ups or run and a P3 profile was initiated.  

During the 12 July 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported intervertebral disc syndrome with desiccated discs, constant pain, nightly spasm, and tingling in the right leg/buttock.  Physical examination was deferred to the MEB NARSUM, although DJD (degenerative joint disease), HNP (herniated nucleus pulposus), and gout (see below) were noted.  At an examination on 16 August 2002 the CI had a full range of motion (ROM) with mild pain with extension and mild lumbar paraspinal tenderness to palpation.  Sensation was normal and straight leg raising (to determine nerve root irritation) was negative.  The 11 September 2002 MEB NARSUM examination, 4 months prior to separation, noted complaints of occasional tingling sensation in his buttocks, hip, and back of his right upper leg; and the pain increased with running or excessive walking.  The pain worsened after standing for prolonged periods, staying in one position for long periods of time, or with any lifting.  He also reported daily back spasms and that sit-ups caused extreme pain.  Physical examination showed a full ROM, flexion, and mild pain with extension, but he could extend normal ROMs without pain on rotation and side bending.  He had a negative straight-leg raise (to determine nerve irritation), normal deep tendon reflexes, and normal sensation bilaterally in his lower extremities.  His pulses were intact.  He had some mild tenderness to palpation in the paraspinal muscles in his lumbar region, but the examination was otherwise unremarkable.  

X-rays of the thoracic spine on 12 February 2003 demonstrated very minimal scoliosis and a few scattered minor osteophytes.  On 10 March 2003, 2 months after separation, the CI reported pain with prolonged sitting or standing and tingling/numbness in the right buttock region.  On examination of the lower extremities, sensation was intact to light touch and cold.  Motor strength was 5/5 bilaterally, reflexes were 2+ bilaterally symmetric, and straight leg raising was negative bilaterally.  The CI was able to toe touch 21 inches from the floor and the paraspinal muscles were nontender bilaterally.  The examiner’s assessment was chronic low back pain without evidence of lumbar radiculopathy.  The pain did not appear myofascial.  The CI took Percocet (oxycodone, a narcotic, and acetaminophen, a pain reliever).  Salsalate, an NSAID, replaced Vioxx (rofecoxib, an NSAID) and Motrin (ibuprofen, an NSAID).  Methadone, a long-acting opioid medication, was added to the treatment regimen, which for the chronic low back pain and gout (see below).  X-rays of the lumbosacral spine on 1 April 2003 demonstrated a partially sacralized L5 and some decrease in height of the L5-S1 disc space as well as minor anterior osteophyte formation at L1-L2.  

At the 7 July 2003 VA Compensation and Pension (C&P) evaluation, 6 months after separation, the CI reported low back pain since 1992 and 1993.  He had intermittent fatigue, but was able to carry on all activities including working a 40 hour week.  Physical examination showed a normal gait.  The ROM measurements of the lumbar spine were all normal based on the VA ROM standards at the time.  Forward flexion was 95 degrees, hyperextension 35 degrees, left and right lateral flexion 40 degrees  each, and right and left rotation 35 degrees each.  The examiner’s diagnosis was degenerative joint disease of the lumbar spine.  

The panel directed attention to its rating recommendation based on the above evidence.  
The PEB rated the back condition 10%, coded 5299-5295 (lumbosacral strain), citing pain on motion.  The VA rated the back condition 0%, coded analogously to 5295, based on the C&P examination 6 months after separation, citing slight subjective symptoms only.  

The panel noted the PEB assigned a 10% rating for the chronic low back pain using the interim spine rules.  A 20% rating, coded 5295 requires lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position, which was not supported by evidence in the STR.  However, use of code 5292 (spine, limitation of motion of, lumbar) offers a 20% option for a moderate disability and a 10% option for a slight disability.  However, at the MEB NARSUM examination the ROM was full as it was at the VA examination, 6 months post-separation, although 2 months after separation the CI was able to toe touch 21 inches from the floor (to knee level (18 inches or just below the knee ~45‐60 degrees).  It was not clear how that disparity of measurement came to be in the absence of an intercurrent accident or injury about which the record is silent.  Therefore, the panel deliberated whether a 20% rating, but no higher, was justified for a moderate limitation of motion; however, since the finding was limited to one time, and measurements before and after were normal, a 20% rating could not be supported.  Furthermore, there was no evidence in this case that motor weakness or sensory impairment existed to any degree that could be described as functionally impairing.  The panel also considered rating the back condition using VASRD diagnostic code 5293 based on incapacitating episodes due to intervertebral disc syndrome.  The criteria are based on the number of incapacitating episodes in the prior 12 months requiring bed rest prescribed by a physician.  However, no documented physician-directed bed rest was evidence in the service treatment records or at the time of the VA C&P examination.  The panel concluded the evidence did not support a higher rating using code 5293.  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 low back pain condition.  

Contended PEB Conditions:  Chronic Intermittent Gout, Bilateral Knee Medial Degenerative Joint Disease, Central Serous Retinopathy, and Hailey-Hailey Disease.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  
Knee and eye conditions were profiled and implicated in the commander’s statement; however, all contended conditions were determined to be medically acceptable.    

Chronic Intermittent Gout.  An MEB NARSUM Addendum dated 5 July 2002 indicated the CI had an insidious onset of knee and ankle pain in 1990-1991.  In 1998 he had a severe bout of pain, swelling and redness in the right ankle, which was aspirated.  Crystals were observed and gout was diagnosed and treated with Indocin (indomethacin, an NSAID) and colchicine (an anti-inflammatory medication) at the time of symptoms.  A note dated 20 July 2001 indicated he took Vioxx daily for the knee/ankle pain, while a note on 6 October 2003 indicated the CI was treated for Lyme disease marked by swollen joints and headaches with Zithromax (azithromycin, an antibiotic).  On 28 October 2003, it was noted that Bextra (valdecoxib, an NSAID) worked very well for the gout, and when he used the medication twice a day the gouty flares resolved quickly (in approximately 2 days).  The note also indicated the plan of treatment also included allopurinol (to lower the uric acid level).

Bilateral Knee Medial Degenerative Joint Disease.  The CI reported he had some cracking of the knee with some pain every morning, but the pain was aggravated, and effusions developed with increased levels of activity.  On examination on 5 July 2002 the CI’s knees showed no joint line tenderness or any effusions.  The ROM measurements were 0 to 135 degrees (normal 0-140).  There was no laxity or evidence of a meniscal tear bilaterally and a grind test was negative bilaterally.  
X-rays of the knees dated 1 April 2003 demonstrated bilateral minor degenerative changes and mild narrowing of the right medial compartment, but were otherwise unremarkable.  

Central Serous Retinopathy.  A note dated 17 May 2002 indicated the CI was diagnosed with central serous retinopathy (fluid buildup under the central portion of the retina (macula)) for 8 months.  He indicated he had a fuzzy spot in the left eye and also had decreased visual acuity at night.  The examiner concluded the CI most likely had chronic central serous retinopathy in the left eye, but saw no evidence of activity and the CI’s visual acuity was relatively good (20/30 right and 20/25 left with correction).  No treatment was necessary at that time, but should recurrent symptoms were to occur, the CI was advised to be re-examined at that time.  A note dated 28 October 2003 indicated the CI had diplopia (double vision) and had prism lenses in place.  

Hailey-Hailey Disease.  A note dated 11 April 2003 indicated the CI had a pruritic (itchy) rash in the groin since 1992.  A dermatology clinic telephone conversation dated 21 May 1998 indicated pathology revealed acantholytic dermatosis with Hailey-Hailey disease favored over Darier’s disease.  Since the time of the biopsy, the CI took doxycycline (an antibiotic with anti-inflammatory effects) and applied Westcort (a topical steroid, hydrocortisone valerate) ointment, which helped.  At the 7 July 2003 VA C&P examination of the genitalia revealed reddened nodules around the corona, redness in the intertriginous spaces (between the thighs and scrotum), redness throughout the groin areas including the scrotum with some lichenification (thickening), and bleeding areas throughout the scrotum.

There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation, and were separately unfitting.  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 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 chronic intermittent gout; bilateral knee medial degenerative joint disease; central serous retinopathy and Hailey-Hailey 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160628, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170014158, 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