RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00064
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040715

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Human Resources Specialist, medically separated for “refractory myofascial low back pain” with a disability rating of 10%.  

CI CONTENTION:  She still has lower back pain.  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 - 20040409	VARD - 20041222	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Refractory Myofascial Low Back Pain	5299-5237	10%	Degenerative Facet Joints, L4-S1 with Mild Lumbar Instability	5242	10%	20041028	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Refractory Myofascial Low Back Pain (LBP).  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in January 2002 after receiving a lumbar epidural anesthetic during delivery of her child.  Pain became constant in April 2002 and a chiropractor assessed lumbosacral myofasciitis in mid-May 2002.  X-rays on 29 May 2002 showed normal lumbar spine curvature and alignment with well-maintained disc spaces, no significant degenerate disc disease, and normal appearing underlying sacroiliac joints bilaterally.  During the 5 August 2002 primary care clinic (PCC) appointment, examination of the lower spine showed bilateral straight leg raise testing (to determine nerve root irritation within normal limits.  Pain was noted with all trunk motions and was greatest with extension and flexion.  Magnetic resonance imaging (MRI) on 22 August 2002 showed lumbar vertebral bodies of normal height, alignment and marrow signal.  There was no evidence of an abnormal enhancement or mass, focal disc protrusion, or significant spinal canal stenosis.  

In the emergency room on 25 April 2003, the CI complained of lower back pain rated at 9/10.  The examiner noted diffuse tenderness throughout the lower back and buttocks as well as the upper posterior thighs.  Neurologic findings were unremarkable.  The differential diagnosis included an epidural abscess, lumbar strain, degenerative disc disease, and chronic LBP.  Treatment included intravenous pain medications, a muscle relaxer, and a steroid.  An MRI demonstrated a normal contour and discs at all levels, and no spinal stenosis.  

At the 5 May 2003 rheumatology appointment, physical examination of the lower back showed tenderness down the spine to the sacrum with no paraspinal muscle tightening.  There was no erythema or warmth, but there was swelling overlying the sacrum.   The examiner’s assessment was chronic myofascial back pain.  Bone scan imaging showed no increased uptake in the sacroiliac joints or pelvic bones.  During a 23 May 2003 rehabilitation visit for a second opinion on CI’s pain etiology, the examiner noted she ambulated with crutches and had an antalgic gait with limping to the right when not using the crutches.  There was tenderness to light touch throughout the L5-S1 area, and she had right-sided pain that may have been a trigger point radiating across her low back.  She was unable to flex forward without pain.  Extension was 10 degrees (normal 30), and side bending and rotation were symmetric at 15 degrees (normal 30).   

At a 10 July 2003 PCC visit, range of motion (ROM) measurements were active flexion to 40 degrees (normal 90) and combined ROM of 140 degrees (normal 240).  There was tenderness over the paraspinals and neurologic evaluation was unremarkable.  An MRI on 16 October 2003 showed a stable lumbar spine with minimal posterior broad based disc bulges at L4-L5 and L5-S1.  During the 12 November 2003 orthopedics appointment, the CI complained of stabbing pain that was aggravated by sitting, walking and standing.  She had occasional numbness and radiating pain into the right leg with intermittent leg weakness.  The examiner noted a normal posture with an antalgic gait and that she used a cane.  

The 2 February 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of severe lower L5-S1 and left sacroiliac joint-type back pain.  Physical examination showed the CI was in no acute distress and ambulated without difficulty.  She had good lower extremity strength and no obvious musculoskeletal deformities.  ROM measurements recorded active flexion to approximately 45 degrees before she stopped due to subjective pain.  Extension was 20 degrees and right and left lateral flexion were 45 degrees on each side.  Straight leg raise testing was negative for radiating symptoms.  The 26 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), less than 5 months before separation, showed the CI with an antalgic gait, and recorded ROM goniometric  measurements  of active flexion to 60 degrees with pain and a combined ROM of 200 degrees.  

At the 28 October 2004 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported LBP that radiated to the right lower extremity with symptoms of numbness, pain, and tingling.  Physical examination showed the CI had an upright posture and walked with a limp due to pain radiating from the back to the right lower extremity.  Goniometric thoracolumbar ROM measurements were active flexion to 75 degrees and a combined ROM of 150 degrees.  Pain, fatigue and weakness were all noted throughout.  There was an additional limitation of motion of about 25% after repetitive use.  X-rays of the lumbosacral spine demonstrated mild degenerative facet joint with L4-S1 minimal to mild lumbar instability.  The final diagnoses was “muscle sprain of the lumbosacral spine with moderate loss of range of motion and moderate loss of functional capacity and radiculopathy affecting the right lower extremity.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5299-5237 (lumbosacral spine strain), citing motion limited by pain.  The VA rated the LBP condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P evaluation 3 months after separation, citing limitation of forward flexion.  Members agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the NARSUM and MEB examinations prior to separation.  Although the C&P evaluation reported flexion of 75 degrees, the limitation of motion was not quantified with repetition.  The panel determined the probative value of the service examinations carried a higher probative value and were consistent with and representative of clinical and imaging findings prior to separation.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the refractory myofascial LBP condition, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the refractory myofascial low back pain condition, the panel unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Refractory Myofascial Low Back Pain	5299-5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170102, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180003288, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure