RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2016-00422
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20031213

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Utilities Equipment Repairer, medically separated for “chronic low back pain” and “chronic pain, right hand and left thigh,” each rated 10%, with a combined disability rating of 20%.   

CI CONTENTION:  The CI contends that “the Physical Evaluation Board did not thoroughly investigate all conditions” and requests that the PDBR “review 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 - 20031007	VARD - 20050121	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5299-5237	10%	Lumbosacral Strain…	5237	20%	20040211	
Chronic Pain, Right Hand and Left Thigh	5099-5003	10%	S/P Right Boxer Fracture 	5220	0%		
			Residuals, Stress Fracture, Left Thigh	5251	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began in September 2002 after a hard parachute landing.  Neuroimaging showed no abnormalities.  Primary care and orthopedic examination notes from May – July 2003 indicated full active range of motion (ROM).  

The 10 September 2003 MEB NARSUM examination, 3 months prior to separation, noted complaints of continued pain without radiculopathy.  The orthopedic physical examination showed full active ROM without pain.  There was a likely positional apparent trunk shift with tenderness to the sacroiliac joints.  The lower extremities showed 5/5 muscle strength and normal neurological findings.
 
At the 11 February 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported constant back pain more severe with any movement and radiation to both legs.  The pain was relieved by rest and medications.  He could function with medication at the time of the pain.  He reported incapacitating episodes up to 3 times per month, which lasted for 3 days.  The examiner noted that a physician had recommended bedrest for 3 days on 2 September 2003.  The functional impairment was an inability to walk, run or carry heavy objects.  The examiner noted that the condition resulted in 2 months of time lost from work.  The was able to perform activities of daily living but was unable to vacuum, climb stairs, take out trash, shop, garden or push a lawn mower due to increasingly severe back pain.  The CI was not employed at the time of the examination and his last date of employment was 13 December 2003.  Physical examination showed normal posture and gait.  ROM showed flexion of 60 degrees (normal 90) and combined ROM of 210 degrees (normal 240).  ROM was additionally limited by pain, fatigue, and weakness; pain had the major functional impact.  There were no signs of intervertebral disc syndrome.  Gross examination of the spine was within normal limits.  When he bent over to touch his toe, he had obvious spasm of the lower right paraspinal muscles.  With straight leg raise testing, he had pain shooting down his leg.  He also had pain with dorsal flexion of the ankle, but no change with plantar flexion which suggested sciatica.  During the 11 July 2004 VA clinic visit, 7 months after separation, the examiner noted that the CI’s ROM had remained intact and that the CI could bend all the way down and squat.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 10%, coded 5237 (analogous to lumbosacral strain), citing low back pain without neurologic abnormality or limitation of motion with localized tenderness.  The VA rated the back 20%, coded 5237, based on the C&P examination 2 months after separation, citing flexion limited to 60 degrees.  The panel noted that each examination were nearly equidistant to the time of separation; the MEB was conducted 3 months pre-separation while the C&P examination was conducted 2 months post-separation.  The panel noted that the limitation of thoracolumbar motion recorded in the MEB NARSUM examination met the threshold for a 10% rating.  The VA noted flexion ROM of 60 degrees with pain which supports a 20% rating.  The panel majority placed greater probative value on the NARSUM examination since it preceded separation and findings aligned with previous ROM findings.  

Although there was insufficient limitation of motion to support a 10% rating, the panel agreed a 10% rating was justified for the presence of tenderness.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  Although there was one documented report of intervertebral disc syndrome (IVDS) with incapacitating episodes in the past year, but it was only for 3 days and would not provide for a higher rating under the formula (for IVDS).  There was no evidence of a ratable peripheral nerve impairment which would provide for additional rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic back pain.  

Chronic Pain, Right Hand (dominant) and Left Thigh.  

Right Hand.  According to the STR and the MEB NARSUM, the CI’s right hand pain began in March 2003 from an injury sustained while changing a tire on his car.  Radiographic studies showed a fracture at the base of the right 5th metacarpal bone.    The 10 September 2003 MEB NARSUM examination, 2 months prior to separation, noted complaints of right hand pain on the 4th and 5th metacarpals after the fracture.  Physical examination of the hand showed tenderness over the metacarpophalangeal joints of the 4th and 5th digits.  

At the 11 February 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported a Boxer’s fracture in his right hand in 2003 with residual of constant aching pain that became worse in cold weather.  With severe pain, there was difficulty with writing.  He could tie shoelaces, fasten buttons and pick up paper without difficulty.  Physical examination showed right thumb ROM with radial and palmar abduction each at 70 degrees (normal), MP flexion at 60 degrees (normal), and IP flexion 60 degrees (normal).  Right index finger ROM was DIP flexion at 90 degrees (normal), PIP flexion at 100 degrees (normal), and MP flexion at 90 degrees (normal).  Right long finger ROM was DIP flexion at 90 degrees (normal), PIP flexion at 100 degrees (normal), and MP flexion at 90 degrees (normal).  Right ring finger ROM was DIP flexion at 90 degrees (normal), PIP flexion at 100 degrees (normal), and MP flexion at 90 degrees (normal).  Right little finger ROM was DIP flexion at 90 degrees (normal), PIP flexion at 100 degrees (normal), and MP flexion at 90 degrees (normal).  The examiner opined there was no diagnosis because the condition was resolved.  

Left Thigh.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left thigh pain began in September 2002 after a hard parachute landing.  Bone scan March 2003 showed increased uptake on the left tibia and left femur, correlating with shin and thigh pain.  The 10 September 2003 MEB NARSUM examination, 3 months prior to separation, showed full ROM of the lower extremities with no deformities and no tenderness.  

At the 11 February 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported pain in the left thigh 1-4 times per year with each occurrence lasting for 1-2 days.  During flare-ups there was pain with walking but he could perform daily functions.   There was no functional impairment or time lost from work.  Physical examination showed left hip ROM of flexion at 125 degrees (normal), extension at 30 degrees (normal 20), external rotation at 60 degrees (normal 45), abduction at 45 degrees (normal), adduction at 25 degrees (normal).  Left knee ROM was 0-130 degrees (normal 0-140).  The examination of the femur, tibia and fibula was within normal limits.  The examiner opined that there was no diagnosis because the condition was resolved.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right hand and left thigh conditions into a single unfitting condition rated 10%, coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA rated the right hand and left thigh separately at 0% each, coded 5220 (favorable ankylosis of the digits of one hand) and 5251 (limitation of thigh extension), based on the C&P examination 2 months after separation, citing a lack of limitation of ROM for each condition.  

The panel first considered if the right and left thigh conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel found that both conditions were profiled, but the commander’s statement implicated only the right hand and not the left thigh.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled right hand and left thigh conditions were reasonably considered separately unfitting.  

Panel members agreed there was no pathway to a rating higher than the 10% adjudicated by the PEB.  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 thigh and right wrist pain.   

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 20%, but elected not to submit a minority opinion.  In the matter of the left thigh and right wrist conditions and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 0%, but elected not to submit a minority opinion.  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 20160625, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

	

AR20170015565, 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,					       
						      					
Enclosure