RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX  	CASE:  PD-2017-05567
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Radiology Specialist, medically separated for “chronic back pain” with a disability rating of 10%.    

CI CONTENTION:  “Received 0% PTSD and 20% for back.  However I am disabled via social security and unemployable via VA.”  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 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 - 20051011	VARD - 20050818	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Degenerative Change and Bulging Disc, Thoracolumbar Spine	5243	10%	STR	
Post-Traumatic Stress Disorder (PTSD)	Not Unfitting	PTSD	9411	10%	STR	
COMBINED RATING:  10%	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’s low back condition began in 2003 after being violently thrown around the gunners hatch of his vehicle while deployed.  Radiologic imaging revealed cervical and thoracic degenerative changes about various levels, and despite various treatment modalities, to include physical therapy and narcotic medications, he had no significant LBP relief.

The 25 August 2005 MEB NARSUM examination, 4 months prior to separation, simply reported the chronology of the CI’s condition.  Physical examination revealed low back tenderness without evidence of spasm, and thoracolumbar range of motion (ROM) was normal, but painful; peripheral strength was normal.  

At the 15 November 2005 VA Compensation and Pension (C&P) examination, 1 month prior to separation, the CI reported daily LBP that was non-radiating in nature and aggravated by sports activities, standing, sitting, lying or lifting.  The examiner recorded normal gait and posture, and flexion was to 85 degrees with a combined ROM of 220 degrees.  Lower extremity neurological tests, deep tendon reflexes, and muscular strength were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain), citing near normal ROM limited by pain with tenderness to palpation.  The VA also rated the low back condition 10%, but coded 5243 (intervertebral disc syndrome), based on the STR, citing flexion of 85 degrees and combined ROM of 220 degrees.  Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) as reported at the VA examination, which was most proximate to separation.  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.  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 low back condition.  

Contended PEB Condition:  PTSD.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not implicated in the commander’s statement, but was profiled as S3 and failed retention standards.  The STR indicated that the CI returned from deployment in September 2004, and while being worked up for LBP, he also reported various adverse psychiatric symptoms to his primary care provider in January 2005, 4 months after returning from deployment.  At that time, psychiatric medication was started for the diagnosis of single episode major depression.  A follow-up encounter in February 2005 noted some improvement in symptoms and he was released without limitations.  His psychiatric medication prescription was filled on the same day as the (February) follow-up encounter, with refills lasting through August 2005 if taken as prescribed.

In July 2005, the CI self-sought mental health (MH) counseling with a licensed social worker and reported insomnia, nightmares, waking up from sleep, some irritability, poor appetite and feeling bad about himself.  He denied suicidal and or homicidal thoughts or feelings, and the counselor additionally documented the following history: “feeling restless, anxiety with persistent worry which comes and goes, high irritability easily aggravated.  Recently received two weeks leave because he was vocal regarding somethings he didn't agree about in the unit.  Quick to take offense, overreacting to real or imagined slights or failures, depression as a chronic condition, loss of pleasure, difficulty functioning at work and no behavioral complaints.”  The previously prescribed psychiatric medication was not listed in this treatment encounter as an active medication within the military pharmacy treatment facility.  A follow-up visit, 1 month later, did not document any significant change to the CI’s ongoing symptoms especially that of “feeling bad” and “overwhelming fatigue.”  The counselor also noted some discussion of marital issues. The mental status examination was normal except for mood that was described as unhappy, depressed, anxious, and frustrated.  His overall appearance was described as “tired,” and the diagnosis was acute PTSD.  There was no listing of an active psychiatric drug on this encounter.  

On 7 September 2005, the CI had his first encounter with a physician regarding his MH symptoms, which were nearly unchanged from previous counseling sessions.  Specifically, he primarily complained of insomnia and irritability secondary to PTSD.  His mood was described as depressed and despairing, but his appearance, behavior, attitude, affect, cognitive functioning and thought processes were either normal or not impaired.  The diagnosis was documented as “chronic PTSD,” and psychiatric medication was changed and re-started.  The CI was released without limitations with instructions to follow-up in 1 week, but there were no further in-service MH follow-up treatments notes found in evidence.     

After extensive deliberation, panel members agreed that despite an S3 profile and a variety of subjective, and to a much lesser degree of objective, adverse MH findings (all of which related to both the deployed and home/work environments), strict evidence to conclude that the PTSD interfered with duty performance to an unfitting degree was not found.  Thus, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended PTSD, so no additional disability rating is 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 PTSD, the panel agrees that it was not a separately unfitting condition and cannot recommend it for an additional disability rating.  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.  

ARXXXXXXXXXXX, XXXXXXXXXXXXXXX

Dear XXXXXXXXXXX:

	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.