RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04603
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060714

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 “low back pain” and “exercise induced bronchospasm,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

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 - 20060516	VARD - 20061206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Recurrent Lumbar Strain	5242	20%	20060920	
Exercise Induced Bronchospasm	6699-6602	0%	Asthma	6699-6602	10%	20060831	
Right Ankle/Foot Pain	Not Unfitting	Right Ankle and Foot Injury	5271	10%	20060920	
DeQuervain’s Right Wrist, Pain Resolved 		Right Wrist Injury	5215	0%	20060920	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in November 2004 during a deployment to Iraq, when she stepped into an improperly grounded shower, was shocked, and fell directly on her back.  In January 2006, X-rays showed a questionable L5-S1 pars defect (spondylolysis or stress fracture of the vertebral arch) with 14 degrees of scoliosis and some hyperlordosis; a subsequent CT scan showed no L5-S1 spondylolysis.  There was no surgical indication.  An orthopedic examination on 15 December 2005, 7 months prior to separation, revealed normal spinal curvature, tenderness, and no muscle spasm.  Thoracolumbar evaluation indicated “full range of motion (ROM) without exceptions,” and painful motion was documented with a positive Patrick-FABER test (for hip pathology) on the right side of the sacroiliac joint.  

The 27 March 2006 MEB NARSUM examination, 4 months before separation, noted CI complaints of chronic back pain.  Physical examination showed right sacroiliac joint tenderness without muscle spasm.  Back ROM and painful motion were not addressed, and the diagnosis was low back pain secondary to sacroiliac dysfunction.  The 18 April 2006 MEB physical therapy (PT) examination, 3 months prior to separation, showed active thoracolumbar flexion to 50 degrees (normal 90) and combined ROM of degrees (normal 240); painful motion was not addressed.  

At the 20 September 2006 VA Compensation and Pension (C&P) joint examination, 2 months after separation, the CI reported continued low back pain.  Physical examination revealed no spinal tenderness or muscle spasm.  Lumbar flexion was 90 degrees and combined ROM was 240 degrees, without painful motion.  No repetitive motion was specified, however, the examiner stated “from a functional standpoint, her lumbar spine has flexion to sixty degrees with twenty-five degrees of extension and lateral bending due to recurrent mild lumbar strain.”  X-rays revealed mild increased lordosis and congenital partial sacralization of L5.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing spinal tenderness and combined passive ROM to 250 degrees, with likely application of AR 635-40, B-29.  The VA also rated the back condition 10%, coded 5237, based on the C&P joint examination, citing mild lordosis and flexion to 90 degrees.  Members deliberated over the probative value of the examinations most proximate to separation.  Although the PEB cited combined average passive ROM measurements which are not VASRD compliant for §4.71a ratings, the MEB PT examination documented active flexion to under 60 degrees.  The post-separation VA examination indicated flexion to 90 degrees, with functional loss to 60 degrees of flexion.  The examiner did not specify whether the loss represented application of repetition and DeLuca criteria, and the VA rating was based on flexion of 90 degrees.  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 recorded on the MEB PT examination, and supported by the VA examiner’s assessment of functional loss.  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 the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the back condition, coded 5237.  

Exercise Induced Bronchospasm.  According to the STR and MEB NARSUM, the CI initially received treatment for increasing shortness of breath in May 2004 while deployed, and was using albuterol (inhalational bronchodilator) 12-20 times per day when he was medically evacuated from Kuwait in December 2004.  Exercise pulmonary function tests (PFTs) in January 2005 were consistent with the diagnosis of asthma (FEV-1 of 97% of predicted and an FEV-1/FVC of 83% with decrease after exercise), and the CI was started on Advair (inhalational anti-inflammatory/ bronchodilator).  On 4 November 2005 and 4 January 2006, the CI was treated with oral prednisone (systemic corticosteroid) for asthma.  

The MEB NARSUM examination noted complaints of ongoing asthma triggered by running, exposure to chemicals, molds, animals, and seasonal changes.  The CI was unable to wear a gas mask, Kevlar and vest without experiencing shortness of breath, and asthma medication included Advair and albuterol.  The examiner stated the CI “will” and “should” continue to take her current medications.  A treatment note on 27 March 2006 documented the prescription of Advair, albuterol, Singulair, as well as a burst of oral steroids to treat a peri-oral allergic reaction.  A 4 April 2006 emergency department follow-up documented prescriptions filled for oral steroids, Advair, albuterol, and Singulair.  

During the 21 August 2006 C&P general examination, 2 months after separation, the CI reported taking Singulair (oral indirect-acting bronchodilator), albuterol, and two other medications that she could not recall; medication frequency was not addressed.  Physical examination showed clear lungs bilaterally.  At the 31 August 2006 VA C&P pulmonary examination, the CI complained of asthma, and current medications included Singular, mometasone (inhalational anti-inflammatory), formoterol (inhaled bronchodilator) and albuterol as needed.  Physical examination showed clear lungs bilaterally, and PFTs revealed an FEV-1 of 95% of predicted and an FEV-1/FVC of 80%.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bronchospasm condition 0%, analogously coded 6699-6602 (asthma), citing asthma medication last prescribed in December 2005, and clear lungs.  The VA rated asthma 10%, also coded 6699-6602, based on the C&P pulmonary examination, citing intermittent inhalational treatment.  Members noted that a 30% rating stipulates “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.”  This criteria does not require daily use for inhalational anti-inflammatory medication, and members noted that the STR and VA medication profiles clearly documented the CI used inhalational anti-inflammatory medication (filled in March 2006) and continued through the post-separation VA examinations.  Although the panel noted three courses of systemic corticosteroids in the year prior to separation, at least one course was for an allergic reaction not including asthma.  Therefore the panel agreed that the VASRD §4.97 threshold for a 30% rating was reasonably satisfied in this case, but a 60% rating was not justified in the absence of at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic corticosteroids.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the bronchospasm condition, coded 6699-6602.  

Contended PEB Conditions:  Right Ankle/Foot Pain; De Quervain’s Right Wrist, Pain Resolved.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The right ankle/foot condition was permanently profiled and failed retention standards, but was not implicated in the commander’s statement.  Orthopedic evaluation in December 2005 showed a normal gait and heel/toe walk without weakness, full ROM, and tenderness over the foot and ankle with a positive anterior drawer (laxity) observed.  The NARSUM evaluation also found ankle and foot tenderness, but no instability, swelling, or deformity, and the MEB examination showed a normal arch.  The right wrist condition was not profiled or implicated in the commander’s statement, and did not fail retention standards.  There was wrist tenderness with no instability or ROM deficit, and the physician indicated wrist pain had responded dramatically to a steroid injection and completely resolved.  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, the panel recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the bronchospasm condition, the panel recommends a disability rating of 30%, coded 6699-6602 IAW VASRD §4.97.  In the matter of the contended right ankle/foot pain and resolved DeQuervain’s right wrist pain, 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.  

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	
Low Back Pain	5237	20%	
Exercise Induced Bronchospasm	6699-6602	30%	
COMBINED	40%	

The following documentary evidence was considered:

AR20190005373, 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 withseverance 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
A copy of this decision has also been provided to the Department of Veterans Affairs.