RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX		CASE: PD-2017-04395 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20060303

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Motor Transport Operator, medically separated for “chronic low back pain with radicular symptoms” with a disability rating of 0%.

CI CONTENTION: Review requested of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB). 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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20060131	VARD - 20060710	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Chronic Low Back Pain with Radicular Symptoms	
5299-5242	
0%	Lumbar Strain with Degenerative Disc Disease	5242	20%	20060421	
			Residual L5-S1 Radiculopathy, Right Lower Extremity	8520	20%	20060421	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Chronic Low Back Pain with Radicular Symptoms. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s low back condition began in February 2005 after heavy lifting. In March 2005, he reported right buttock pain for a month, which was treated with a nonsteroidal anti-inflammatory drug (NSAID) and prednisone (a steroid). While deployed, he had pain that radiated down into his legs, and he was subsequently medically evacuated in May 2005.     An MRI performed on 7 June 2005 showed a right paracentral L4-5 disc protrusion with

right lateral recess narrowing and the disc abutting the L5 nerve roots bilaterally. There was also a transitional vertebra designated as L5 and some sacralization. Electrodiagnostic studies on 8 June 2005 showed evidence of denervations in the right lower lumbar paraspinous, extensor hallucis longus, and extensor digitorum brevis muscles suggesting the presence of an L5 root lesion on the right side. The examiner noted the remainder of the studies (electromyography and nerve conduction) to  be  within the range of normal variation.  At an  orthopedic visit on  24 June 2005, the CI was given narcotic medication and a NSAID and was referred to physical therapy (PT) where traction and neural glides were tried with minimal improvement.

At the 28 July 2005 pain management clinic appointment, 7 months prior to separation, the CI reported constant aching and shooting pain and weakness in his right leg. The examiner recorded lumbar flexion to 10 degrees (normal lumbar 60; thoracolumbar 90), based on a fingers-to-floor distance of 20 cm (8 inches), which actually more closely approximates 70-80 degrees of thoracolumbar flexion. Extension was to 5 degrees as were both right and left rotation (normal 30). Palpation and percussion of the thoracic and lumbar spine regions were unremarkable, but straight leg raise (SLR) testing (to determine nerve root irritation) was provocative on the right at 40 degrees. Neurologic examination showed no atrophy or fasciculations, normal muscle strength and tone, and intact light touch, pinprick, thermal (cold tuning fork), vibratory, and joint position sense testing. Stress maneuvers of the hips and sacroiliac joints were non-provocative bilaterally. The CI’s gait was narrowly based with natural posture and arm swing, and tandem, heel and toe walking were performed without difficulty. Movements were smooth and natural with no evidence of tremor or involuntary movements in the extremities. On 8 September 2005, the CI underwent right L4, L5, and S1 lumbar transforaminal epidural steroid injections and/or selective nerve root blocks.

At the 31 October 2005 MEB PT appointment, 4 months prior to separation, the examiner recorded thoracolumbar flexion to 25 degrees and combined range of motion (ROM) of 135 degrees (normal 240). The 22 November 2005 MEB NARSUM examination, 3 months before separation, noted complaints of low back pain with radiation into the lower extremities. Physical examination showed a normal gait and no spinal or paravertebral tenderness. Bilateral SLR tests were positive, but strength and sensation were normal in all four extremities, with 2+ deep tendon reflexes throughout.

At the 21 April 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant back pain that radiated down his right leg, but denied any incapacitation or lost days from work. Physical examination showed paraspinal muscle spasms and tenderness with SLR testing positive on the right, but negative on the left. Thoracolumbar ROM measurements showed flexion to 55 degrees with painful motion, and a combined ROM of 180 degrees. The joint function of the spine was limited by pain, fatigue, weakness, and lack of endurance after repetitive use, but not incoordination. Gait and posture were normal. On the same day, X-rays showed a transitional lumbosacral segment with large transverse processes articulating with the sacrum on both sides, which might be designated L5 (slightly rudimentary), L5-S1 interspace narrowing, and 2 mm retrolisthesis (sliding backward) of L4 relative to L5. There were signs of intervertebral disc syndrome (IVDS), and the examiner found an L5 sensory deficit of the right lateral leg, dorsal foot, and lateral foot with some motor weakness (4/5) during right foot and right toe dorsiflexion. There was also an S1 sensory deficit of the right back thigh, lateral leg, and lateral foot with motor weakness (4/5) during right knee flexion and right foot plantar flexion. There was no bowel, bladder or erectile dysfunction, and the examiner noted the most likely peripheral nerve involvement was the sciatic nerve.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 0%, analogously coded 5242 (degenerative arthritis of the spine), citing no motor neurological abnormality, tenderness or spasm, and ROM limited by pain. The VA rated the low back condition 20%, coded 5242, based on the C&P examination, citing

forward flexion limited to 55 degrees, with tenderness and muscle spasm. The VA also rated the low back radiculopathy 20%, coded 8520 (sciatic nerve paralysis of), based on the C&P examination, citing moderate, incomplete paralysis below the knee. Panel 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) as reported on the VA examination, which carried greater probative value as it was more detailed and compliant with VASRD rating guidelines and closer to separation than the PT examination. 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 recommends a disability rating of 20% for the low back condition, coded 5242.

The panel then considered whether an additional rating could be recommended under a peripheral nerve code. Although the pain component of the neuropathy was appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component other than S1 and L5 sensory deficits of the right leg and foot, which did not cause significant functional impairment. Additionally, there was no significant motor weakness other than 4/5 strength noted with right knee, foot and toe movements at the VA examination. Therefore, radiculopathy could not be recommended for additional disability rating.

BOARD FINDINGS: In the matter of the low back condition, the panel recommends a disability rating of 20%, coded 5242 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 the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain With Radicular Symptoms	5242	20%	

The following documentary evidence was considered:

PD-2017-04395

AR20190012254, XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX

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.