RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01568
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060415

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E5, Armor Crewman, medically separated for “diabetes mellitus, type II” and “chronic low back pain,” rated 20% and 0%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI contends his conditions are degenerative with no cure and have worsened.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20060314	VARD - 20061220	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Diabetes Mellitus, Type II	7913	20%	Diabetes Mellitus (Type II)	7913	20%	20060616	
Chronic Low Back Pain	5299-5237	0%	Degenerative Disc Disease (DDD)	5239-5242	20%	20060616	
Carpal Tunnel Syndrome (CTS) Bilateral	Not Unfitting	CTS, Right	8599-8515	10%	20060616	
		CTS, Left	8599-8515	10%	20060616	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Diabetes Mellitus, Type II.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s diabetic condition was discovered in January 2005 during the demobilization process when the CI was found to have glucose in his urine.  Additional lab studies at that time showed a fasting blood sugar of 402 (elevated) and an initial hemoglobin A1C of 10.5 (elevated).  There were no complaints of nocturia, polyuria, or frequency in urination; however, the CI reported drinking a lot of water every 30 minutes while deployed to Iraq, which was very hot.  He was started on oral medications (Metformin and Glucotrol XL).  

The 28 December 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of diabetes, leg, and back pain.  The CI had undergone diabetic education and Rosiglitazone had been added to his medication treatment.  Laboratory testing showed 2+ glucose in the urine (abnormal), blood glucose of 173 (slightly high if fasting), and HgbA1C at 7.5 (above desired).  The physician indicated the CI’s diabetes was “fairly under control” and “with peripheral neuropathy as complication.”  

At the 16 June 2006 VA Diabetes Compensation and Pension (C&P) examination, 2 months after separation, the CI reported no increased frequency of urination or decreased sensation to his lower extremities.  He was on a diabetic diet, was taking oral medications, and had no activity restrictions.  Physical examination documented no lower extremity weakness.  Urine microalbumin test was negative for diabetic nephropathy and no renal insufficiency was noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the diabetic mellitus, type II condition 20%, coded 7913 (diabetes mellitus), citing fair control on oral medications and noting peripheral neuropathy of the lower extremities secondary to diabetes.  The VA also rated the diabetes mellitus type II with retinopathy condition 20%, coded 7913 (diabetic mellitus), based on the C&P examination, citing a restricted diet and oral medication for control.  

The panel agreed the requirement for an oral hypoglycemic agent and restricted diet justified a 20% rating.  Because there was no evidence of insulin use and medically-prescribed regulation of activities, the next higher 40% rating was not justified.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the diabetic mellitus type II condition. 

Chronic Low Back Pain.  According to the STR and MEB NARSUM, the CI’s low back pain condition began while deployed to Iraq.  He denied any injury or accidents and attributed the low back pain to riding in a Humvee over rough terrain, prolonged use of a flack vest, and walking on gravel and rough terrain.  In March 2005 he was evaluated for his low back pain and was managed conservatively with medications, a profile, and physical therapy.  Lumbar spine X-rays showed intervertebral disc space narrowing.  In May 2005 the CI was found to have significant degenerative disc disease at L5-S1 documented by MRI with posterior lateral annular bulging of the disc and narrowing of the neuro foramina without significant stenosis.  Epidural steroid injections were not effective and surgery was not recommended.  

The 28 December 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of leg and back pains.  Pain was aggravated by activity with more apparent left leg numbness and tingling sensation.  Physical examination showed a normal gait, with no back erythema, edema, or focal tenderness.  Straight leg raise was positive in the left lying position and bilateral sitting.  No motor weakness was noted.  Sensory was decreased to pain and temperature and stimulation, in a stocking glove distribution.  Deep tendon reflexes were symmetric at +1.  Range of motion (ROM) of the thoracolumbar spine (accomplished by physical therapy on 3 January 2006) showed flexion of 90 degrees (normal) and combined ROM of 235 degrees (normal 240).  

At the 16 June 2006 C&P General Medical examination, 2 months after separation, the CI reported lower back pain at the L5-S1 level paraspinal area.  Pain radiated from the lower back into the left buttocks and down to the left foot on occasion, with reported stiffness but no weakness.  He had flare-ups with heavy lifting or prolonged sitting and used Motrin.  

Physical examination showed normal gait.  ROM of the lumbosacral spine showed forward flexion of 40 degrees and combined ROM of 165 degrees.  Painful motion and spasm were noted.  Repetitive use showed no fatigue, no incoordination, no lack of endurance, and no additional loss of motion by pain.  Tenderness was noted at the L5-S1 paraspinal area; however, no effusion, erythematous changes, or muscle atrophy was noted.  Neurological examination of the lower extremities was normal.  Lasegue sign was positive for the left lower extremity, indicating lumbar radicular symptoms.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 0%, coded 5299-5237 (analogous to lumbosacral strain), citing “flexion of 90 degrees and extension of 16 degrees, measurements not limited by pain … MRI showed signification degenerative disc disease at L5-S1” [Note active extension was 25 degrees of normal 30].  The VA rated the degenerative disc disease condition 20%, coded 5239-5242 (spondylolisthesis or segmental instability - spinal fusion), based on the C&P examination, citing forward flexion to 40 degrees.  

The panel deliberated on the probative value of the examinations in evidence, and adjudged that the PT ROMs aligned with the majority of the pre-separation evaluations and had the highest probative value for rating at separation.  The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB PT examination.  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.  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 10% for the chronic low back pain condition, coded 5299-5237.  

Contended PEB Condition:  Carpal Tunnel Syndrome (CTS), Bilateral.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition (either left and/or right CTS) was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement, nor judged to fail retention standards.  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 there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the diabetes mellitus, type II condition and IAW VASRD §4.119, the panel recommends no change in the PEB adjudication.  In the matter of the chronic low back pain condition, the panel recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the contended bilateral CTS condition, the panel agrees it cannot recommend it for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows; and, the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Diabetes Mellitus, Type II	7913	20%	
Chronic Low Back Pain	5299-5237	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170214, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180004891, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,					      
Enclosure