RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE: PD-2019-00027 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20091215

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Bradley Fighting Vehicle System Maintainer, medically separated for “chronic low back pain (LBP)” 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 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 - 20090902	VARD - 20090116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP and Limitation of Motion	5299-5243	10%	Lumbar Strain	5237	10%	20100920	
Post-Traumatic Stress Disorder (PTSD) and Depressive Disorder NOS	

Not Unfitting	PTSD and Depressive Disorder	9434-9411	50%	20091123	
Mixed Tension, Non-Prostrating Migraine Headaches		
No VA Placement	
Hyperlipidemia			
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 70%	

ANALYSIS SUMMARY:

Chronic LBP and Limitation of Motion. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a 2-year history of LBP without trauma which was exacerbated by a deployment to Iraq from November 2005 to October 2006. A lumbar spine MRI in November 2008 showed L4-L5 and L5-S1 disc changes with bulges abutting (compressing) the thecal sac and nerve roots without displacement.

During the 20 March 2009 MEB physical therapy examination, 8 months prior to separation, physical examination showed no abnormal gait or spinal contour. There was guarding but no spinal tenderness or muscle spasm. Painful thoracolumbar range of motion (ROM), measured

with a goniometer, was flexion 90 degrees (normal) and combined ROM 225 degrees (normal 240).

At the 23 November 2009 VA Compensation & Pension (C&P) traumatic brain injury and general examination, 22 days before separation, the CI reported daily LBP that did not radiate or cause numbness, weakness, or tingling. Physical examination revealed a smooth and coordinated gait without an assistive device. He was able to tandem walk, but could not heel-toe walk due to heel pain. Spinal curvature was normal with tenderness. Painful ROM was flexion 80 degrees and combined ROM was 205 degrees after repetition. During the September 2010 C&P examination, 9 months after separation, the CI reported constant daily LBP. Physical examination was identical to the November 2009 C&P findings.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the LBP 10%, analogously coded 5299-5243 (intervertebral disc syndrome (IVDS)), citing limited ROM. The VA also rated the LBP 10%, coded 5237 (lumbosacral strain), based on the C&P examination, citing limitation of flexion. 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) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB and VA examinations. There was no muscle spasm or guarding to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis. There was no evidence 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 LBP.

Contended PEB Conditions: PTSD; Depressive Disorder, NOS (Not Otherwise Specified); Mixed Tension, Non-Prostrating Migraine Headaches, and Hyperlipidemia. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. In the matter of the migraine headaches, and hyperlipidemia, neither of these conditions were permanently P3 profiled or implicated in the commander’s statement, and they did not fail retention standards. There was no performance-based evidence from the record that either of these 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.

PTSD and Depressive Disorder, NOS. According to the MEB NARSUM and STR, the CI deployed to Iraq from November 2005 to October 2006. The CI reported feeling “in great danger of being killed” while deployed, but denied any mental health (MH) symptoms on the Post-Deployment Health Assessment on 11 November 2006. In April 2007, the CI was diagnosed with adjustment disorder after self-referring to mental health due to insomnia, depression, and anger symptoms; subsequently, he attended two troop medical clinic interventions for sleep medication and eating more regular meals. No MH profile was rendered.

The commander’s statement, dated 23 March 2009, rendered the CI incapable of completing his duties/tasks due to his inability to perform heavy lifting. The CI was seen by MH in April 2009 following the suicide death of his cousin and was found to have depression. The 27 March 2009 MEB examination led to the referral for a psychiatric examination. During the 4 August 2009 psychiatric addendum, the CI was diagnosed with delayed onset PTSD and chronic depressive disorder NOS, both of which were opined to be medically unacceptable. The CI was subsequently issued his first physical profile on 24 August 2009, which listed: lumbago permanent L3, and PTSD and depression permanent (S3). The 26 August 2009 MEB Report determined both back and MH conditions were medically unacceptable.

The panel deliberated whether the preponderance of performance-based evidence warranted the CI’s MH condition as unfitting or not unfitting. Panel members agreed that the CI was entered into the MEB process due to his back condition, and the CI’s MH condition was entered after the CI was noted to have MH symptoms during the MEB examination. Panel members also noted that the CI’s MH condition was not profiled until 2009 and the commander statement did not implicate the MH condition as duty limiting. Both those documents were initiated during the MEB Process. Consequently, the panel determined there was not a preponderance of performance-based evidence that the MH condition significantly interfered with satisfactory duty performance. 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 pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended post-traumatic stress disorder, depressive disorder, not otherwise specified, mixed tension, non-prostrating migraine headaches, and hyperlipidemia 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.

DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY
251 18TH STREET SOUTH, SUITE
385
ARLINGTON, VA 22202-3531

AR20190015706

Dear XXXXXXXXXXXXXXX:

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.

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