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Dear XXXXXXXXXX:

	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.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03939
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090627

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 “lumbosacral strain” with a disability rating of 10%.  

CI CONTENTION:  Review of all conditions requested.  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 - 20090305	VARD – 20090929 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Degenerative Disc Disease, Lumber Spine	5243	0%	20009723	
Dyspepsia	Not Unfitting	NSAID-Induced Gastritis	7307	0%	20009723	
Headaches, Non-Prostrating	Not Unfitting	Traumatic Brain Injury (TBI) with Head-Aches and Memory and Specific Issues	8045	NSC	20009723	
History of Mild Concussion	Not Unfitting					
History of Right Ulnar Neuropathy, Resolved	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in May 2007 when he twisted awkwardly moving a tow bar while deployed.  In June 2007 he had two chiropractic treatments that significantly aggravated his pain.  Examination on 5 May 2008 revealed no deformity of the back, a full active range of motion (ROM), and a small amount of muscle spasm in the L2 left paraspinal muscles.  Methocarbamol (a muscle relaxer) was prescribed for the muscle spasm.  X-rays of the lumbar spine, 19 May 2008 showed minimal left convex curvature of the lumbar spine, which may have been positional, but was otherwise unremarkable.  Physical therapy (PT) was instituted on 27 May 2008.  An MRI of the lumbar spine on 5 August 2008 showed spondylosis (spinal degeneration) worse at L2-L3 and L3-L4 and disc bulges at L2 through L4 with small annular tears and no nerve root involvement.  Little improvement was achieved with PT.  Piroxicam, a nonsteroidal anti-inflammatory drug (NSAID), was prescribed on 12 August 2008.  Neurosurgical evaluation on 29 October 2008 indicated the CI denied any radicular symptoms, changes in bowel or bladder function, or lower extremity weakness.  He had PT, chiropractic care, and NSAIDs, all of which had not helped.  On examination he stood with a guarded posture.  There was point tenderness in the upper region overlying the L2 and L3 vertebral bodies with a mild amount of paraspinous spasm.  He was able to fully flex, extend, and laterally bend and rotate.  Motor and neurologic testing was normal and he was able to ambulate on his toes and heels bilaterally.  No surgery was offered based on his examination and imaging studies.  Celecoxib, an NSAID, was recommended, and the CI was medically cleared to perform his infantry duties.  However, because he did not show improvement despite treatment, his limitations prevented him from doing his infantry tasks.  

During the 21 January 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported “arthritis L2 to L4.”  Physical examination revealed pain with palpation of the lumbar spine in the midline and the bilateral paraspinal areas.  The 5 February 2009 MEB NARSUM examination, 5 months prior to separation, noted  complaints of daily low back pain with several episodes a month where he had a sharp spasm or pain that caused him basically to collapse.  Physical examination showed a normal appearance of the lumbar spine.  There was tenderness of the bilateral paraspinous muscles, left greater than right, between L1 and L5, without palpable spasm.  There was pain at the end range of flexion and extension and a little pain at lateral bending and rotation bilaterally.  Neurologic evaluation was unremarkable.  On 5 February 2009, the examiner decided to proceed with an MEB.  Amitriptyline (an antidepressant and for nerve pain) was prescribed and the CI was referred for pain management.  PT measurements on 9 February 2009 for flexion were 120 degrees (90 normal) and the combined ROM was 230 degrees (normal 240) with pain.  

On 18 February 2009, the CI underwent an injection at L3/4 and reported 100% relief for a few days and then the pain slowly returned to baseline.  On 17 March 2009 another injection was given.  X-rays of the lumbosacral spine on 13 April 2009 were normal, while an MRI on 14 April 2009 demonstrated a new L4-5 disc extrusion with no neural compromise and stable disc disease at L2-3 and L4 without neural compromise.  Facet block injections were given on 20 April 2009. 
	
At the 23 July 2009 VA Compensation and Pension (C&P) examination, one month after separation, the CI reported lower back pain.  Physical examination showed the CI’s posture and gait were normal as were his getting on and off the examination table without difficulty. No brace or assistive devices were in use.  There was no paravertebral, sacroiliac, or sciatic notch tenderness or spasms.  Neurologic evaluation was unremarkable.  Flexion was 115 degrees (normal 90) and the combined ROM was normal and without pain.  There were no incapacitating episodes in the prior 12 months.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbar spine strain), citing full flexion with combined ROM at 221 degrees, rated for tenderness and combined ROM of the thoracolumbar spine not greater than 235 degrees in accordance with VASRD General Rating Formula for Diseases and Injuries of the Spine.  The VA rated the degenerative disc disease 0%, coded 5243 (intervertebral disc syndrome [IVDS]), based on the C&P examination, citing a non-compensable evaluation for forward flexion of the thoracolumbar spine of greater than 85 degrees; or, combined ROM of the thoracolumbar spine greater than 235 degrees.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) or combined ROM (greater than 120 degrees but not greater than 235 degrees) as reported on the PT examination proximate to separation.  Additionally, the CI had tenderness and a little pain with motion.  However, 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 IVDS with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all 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 lumbosacral strain condition.  

Contended PEB Conditions:  Dyspepsia; Headaches, Non-Prostrating; History of Mild Concussion; and History of Right Ulnar Neuropathy, Resolved.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement and did not fail retention standards.

Dyspepsia.  The condition began with NSAID use, which the CI discontinued.  He had intermittent GERD (gastroesophageal reflux disease) and epigastric pain associated with spicy foods.  Examination was normal and a trial of Prilosec (omeprazole to treat GERD) was instituted on 5 February 2009.  

Headaches.  At a neurology visit on 23 April 2008 the CI reported a longstanding history of a right frontal headache and a longstanding history of a frequent mild, dull, diffuse headache, which was typically only a mild nuisance.  He also experienced a more severe episode once a month, which was typically right frontal, was associated with photophobia (light sensitivity), and lasted several hours.  It was triggered by poor hydration, stress, or lack of sleep and was chronic and recurring since childhood.  Neurologic examination was normal.  The examiner’s assessment was the characteristics and history were consistent with migraine headaches.  Treatment consisted of magnesium and rizatriptan (for migraines) in conjunction with naproxen, an NSAID.  On 13 March 2009 the CI reported the rizatriptan did not help the headaches and nortriptyline (for nerve pain) was prescribed in its place.  

Mild Concussion.  The CI had an IED blast exposure when deployed in July 2007 and reported a sleep disorder, tinnitus, speech impairment, irritability, and aggression.  He had no loss of consciousness.  The CI scored 29/30 on the Military Acute Concussion Evaluation (MACE), missing one point on concentration and 29 on the PTSD Checklist-Military Version (PCL-M).  He was able to name 24 animals in 60 seconds, which was normal. On 13 March 2009 an MRI of the head was reported to be normal with probably congenital mild lateral ventriculomegaly (fluid-filled spaces in the brain); also normal were neurologic and mental status examinations except for a depressed mood.  Vitamins B1 and D were prescribed.  

Right Ulnar Neuropathy, Resolved.  No details were available in the STR to review.

There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended dyspepsia; headaches, mild concussion; and right ulnar neuropathy conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.