RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03860
BRANCH OF SERVICE:  ArmY	SEPARATION DATE:  20061011

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Infantryman, medically separated for “chronic low back pain” with a disability rating of 0%.  

CI CONTENTION:  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 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 - 20060627	VARD –20070810	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	0%	Lumbar Strain	5237	10%	20070228	
Optical Field Loss	Not Unfitting	Right Homonymous Hemianopsia	6080	30%	20070730	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI initially sought treatment for his LBP in April 2004, reporting a 4 to 5-year history of LBP with no record of injury or trauma.  At the 15 April 2004 physical therapy clinic appointment the CI reported he had back pain daily over the past couple of months to include an episode of severe pain and spasm 4 weeks earlier.  Physical examination showed tenderness in the lower back and full active range of motion (ROM) with pain at end of range flexion.  The CI was given instruction on exercises to perform and was allowed to deploy to Afghanistan with his unit later that week, and ultimately completed a 10 month deployment.  After return, he continued to complain of LBP.  At a 14 April 2005 physical medicine and rehabilitation clinic appointment he reported pain originating in his lumbosacral spine radiating to his left lateral thigh with associated numbness and dysesthesias, exacerbated by trunk flexion and alleviated with stretching.  He denied any lower extremity weakness.  The examiner reported that X-rays of the lumbar spine were normal and diagnosed a lumbosacral paraspinal muscle strain.  A CT scan on 8 June 2005 showed a broad-based protrusion at L5-S1 and a broad-based bulge at L4-5, without evidence of neural involvement or canal stenosis.  

At the time of his 5 October 2005 primary care clinic appointment, the CI reported a history of LBP, with no pain radiating to the legs and no leg weakness or numbness.  Physical examination showed a normal gait and stance, with tenderness reported in the lower back and sacrum.  Lower extremity sensation, strength, and reflexes were all normal.  

The 23 November 2005 MEB NARSUM examination, 11 months prior to separation, noted complaints of persistent LBP with intermittent episodes of pain radiating down to his right lateral thigh, aggravated by wearing military equipment including Kevlar helmet, rucksack, or load bearing equipment.  He denied lower extremity weakness.  Physical examination showed a normal appearing spine.  Thoracolumbar ROM was flexion of 90 degrees (normal) and combined ROM of 215 (normal 240) with painful motion.  There was no mention of spasm, guarding, or abnormal gait.  Lower extremities had normal strength, sensation, and reflexes.  

At the 28 February 2007 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported constant, moderate to severe pain of the lumbar spine, making it difficult to sit or stand for more than an hour, walk for more than half an hour, and bend/lift more than 40 pounds.  He denied pain radiation to his lower extremities and also denied any incapacitating episodes in the previous 12 months.  X-rays of the lumbar spine showed no arthritis.  Physical examination showed a normal gait.  Goniometric ROM measurements after repetition showed flexion of 90 degrees and combined ROM of 230 degrees, with mildly painful motion, minimal spasm, and minimal tenderness.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, analogously coded as 5237 (lumbosacral strain), citing painful motion.  The VA rated the back condition 10%, analogously coded as 5237, based on the C&P examination, citing ROM limited by pain.  

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 NARSUM and VA examinations.  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 back condition, coded 5299-5237.  

Contended PEB Condition:  Optical Field Loss.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition (visual and neurologic) was implicated in the commander’s statement and the E3 profile dated 21 December 2005, was changed to a final E2 profile dated 5 April 2006 with limitations of no driving a military vehicle and no night operations.  The condition was not judged to fail retention standards.  

In 1990, prior to entry, the CI had resection of a left parietal meningioma with residuals of right sided visual defects that resolved prior to entry.  Entry physical and neurology consultation in 1999 documented full visual fields.  The CI indicated he had been exposed to a blast injury (per CI and VA records in 2002) when a mine detonated approximately 8 feet from his vehicle (per commander’s statement) with apparent temporary visual loss.  In February 2005, the CI was medically evacuated from theater for headaches and the CI had complaints of increasing right sided visual field cuts.  Optometry evaluation in March 2003 documented right inferior quadranopsia (dense OD [right eye], less dense OS [left eye]) and (less dense) right superior field loss OD.  Follow-up ophthalmology, optometry, and neurology evaluations indicated slight worsening of the visual fields loss, and fixed visual field deficit on multiple repeated formal testing.  Central visual acuity was preserved.  There were no visual symptoms associated with the CI’s headaches.  On 28 July 2005, neurology recommended restriction to no driving.  MRI in September 2005 documented no evidence of repeated parietal tumor, and unchanged focal post-surgical defect surrounded by post-surgical encephalomalacia in the left parieto-occipital region.  Visual fields on 11 August 2005, 14 months prior to separation, documented right inferior quadranopsia OU [both eyes] and slight right superior field loss OU with slight left inferior field loss OD.  

The VA Optometry C&P examination on 9 February 2007 (4 months after separation), with follow-up evaluation on 30 July 2007, provided a similar history to the STR.  Physical examinations revealed inferior right peripheral defect on confrontation testing and right inferior homonymous quadranopsia (also called right inferior homonymous hemianopsia OU) on repeated testing.  The 30 July 2007 assessment stated:  “Right Inferior homonymous hemianopsia OU.  Goldmann Bowl visual field repeated today, shows repeatable consistent right homonymous hemianopsia with good reliability OU.”  

The panel adjudged that the CI’s duty limitations of no driving a military vehicle and no night operations was unfitting for the CI’s MOS of Infantryman.  The panel next deliberated on the rating IAW VASRD §4.84a criteria in effect at the time of separation (changed effective December 2008).  The STR documented slight progression of the CI’s visual defect with a predominant (right inferior) nonhomologous quadrantopsia of both eyes.  Although the VA examinations were closer to the date of separation, the source visual fields and the more frequent diagnosis of “right inferior homonymous quadranopsia” and “right inferior homonymous hemianopsia” by the VA specialists with a single assessment finding of “right homonymous hemianopsia” indicated by the preponderance of the evidence that the CI’s visual fields did not affect the superior visual fields.  The “right homonymous hemianopsia” was considered an outlier to the remainder of the evidence of record.  The panel adjudged that the STR optometry and source VA evaluations had the highest probative value for rating at separation.  The bilateral right inferior quadrant visual field loss was large, but spared the central vision for each eye.  The panel considered rating each eye analogous to 6081 (scotoma, pathological, unilateral), with the minimum 10% rating for large scotomas for each eye (combined 20%).  However, the average concentric contraction of each eye using the source VA losses at the prime meridians (IAW §4.76a, computation of average concentric contraction of visual fields) was below 45 degrees, but not to 30 degrees bilaterally; therefore satisfying the 30% criteria under code 6080.  After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of optical field loss favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 6080 and meets the VASRD §4.84a criteria for a 30% rating.  

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the contended optical field loss condition, the panel agrees it was unfitting and recommends a disability rating of 30%, coded 6080 IAW VASRD §4.84a.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5299-5237	10%	
Optical Field Loss	6080	30%	
COMBINED	40%	

AR20180015550, 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 40% 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.