RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04788
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090426

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Field Artillery Automated Tactical Data Systems Specialist, medically separated for “right leg weakness and numbness” and “degenerative arthritis in the lumbar spine,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  Conditions continue to worsen and negatively impact daily activities.  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 - 20090116	VARD - 20090723	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Leg Weakness and Numbness	5242-8620	10%	Radiculopathy, Right Lower Extremity 	8599-8520	10%	20090626	
Degenerative Arthritis in the Lumbar Spine	5242	10%	Bilateral L5 Spondylolysis and Grade II Spondylolisthesis	5239-5242	10%	20090626	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Leg Weakness and Numbness.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right leg condition began in August 2007 after a few weeks of insidious back pain and at a time when he was very active in ruck marching and performing heavy lifting.  At the 11 July 2008 primary care clinic appointment, he complained of sharp, shooting pain down the legs, left greater than right, when his feet hit the ground.  The examiner reported no limb weakness, tingling or numbness.  

During the 26 September 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported numbness, tingling and twitches in his right leg.  Physical examination showed normal strength and reflexes and noted subjective decreased sensation in the right thigh and calf that was normal to light touch testing.  

The 8 October 2008 orthopedic MEB consultation reported a normal gait and toe and heeling walking.  Straight leg raise testing was negative, and lower extremity strength, sensation and reflexes were normal.  Electrodiagnostic studies conducted on 7 October 2008 showed evidence of an old L5 radiculopathy with re-innervation.  At the 3 November 2008 MEB NARSUM examination, 6 months prior to separation, physical examination showed normal lower extremity strength, sensation and reflexes.

At the 26 June 2009 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported right leg radiculopathy with flare-ups of back pain associated with paresthesias, weakness, dysesthesias and functional loss.  The paresthesias occurred once every few days and went from the upper posterior thigh down to the calf, but minimally interfered with daily activities.  Physical examination showed normal lower extremity strength, sensation and reflexes bilaterally.  Toe, heel, and heel-to-toe walk were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right leg condition 10%, coded 5242-8620 (degenerative arthritis of the spine – neuritis of the sciatic nerve), citing equivalence to mild incomplete paralysis with subjective symptoms of pain and paresthesia IAW VASRD §4.123.  The VA also rated the right leg condition 10%, analogously coded 8599-8520 (incomplete paralysis of the sciatic nerve), based on the C&P examination, citing mild incomplete paralysis below the knee.  Members agreed that the evidence of pain and paresthesias of the right lower extremity without weakness or sensory loss supports no higher than the 10% rating adjudicated by the PEB.  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 right leg condition.  

Degenerative Arthritis in the Lumbar Spine.  According to the STR and MEB NARSUM, the CI’s back condition began in August 2007 without specific trauma or incident.  He reported low back pain (LBP), especially when lifting heavy objects or running.  Lumbar spine X-rays showed bilateral L5 spondylolysis with grade II spondylolisthesis confirmed by MRI.  The MRI also revealed bilateral neuroforaminal (space through which the spinal nerves exit) narrowing, severe at L5-S1 and mild to moderate at L4-5.  

During the MEB examination, the CI reported recurring LBP when performing duties or lifting more than 20 pounds, as well as back spasms.  The examiner recorded full active thoracolumbar range of motion (ROM) with no erythema, edema, ecchymosis, tenderness or spasm.  The orthopedic MEB consultation showed a normal gait and no tenderness with the CI able to forward flex to 90 degrees (normal) and lateral bend and rotate to each side without pain; however, he did have pain with hyperextension.  

The 3 November 2008 MEB NARSUM examination, 6 months prior to separation, noted complaints of chronic, constant, sharp pain and stiffness throughout the lower lumbar spinal region, aggravated by carrying greater than 10 pounds, walking more than a half mile, doing sit-ups or wearing his body armor, backpack, load-bearing vest or Kevlar helmet.  He reported flare-ups of pain daily.  Physical examination showed full ROM after repetition, with no mention of painful motion, spasm or guarding.  
At the 26 June 2009 C&P examination, 2 months after separation, the CI reported constant daily LBP, but denied incapacitating episodes in the previous 12 months.  Physical examination showed a normal gait and posture.  There was tenderness and muscle spasms of the lumbar spine with full ROM.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), citing painful motion.  The VA also rated the back condition 10%, dual coded 5239-5242 (spondylolisthesis or segmental instability–degenerative arthritis of the spine), based on the C&P examination, citing painful motion.  Members agreed that there was insufficient limitation of motion to support a 10% rating.  However, a 10% rating was justified for the presence of painful motion.  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 concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

BOARD FINDINGS:  In the matter of the right leg condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.    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.  

The following documentary evidence was considered:

[AR NUMBER]  XXXXXXXXXXXXXXXXXX. 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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.

Enclosure