RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200723 SEPARATION DATE: 20020411 BOARD DATE: 20130123 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SFC/E-7 (91W4V/Health Services Specialist) medically separated for chronic thoracic back pain with underlying condition of Scheuermann's Kyphosis. The CI’s mid-back pain had been present since mid-1996. His pain was probably related to an injury suffered when performing a parachute landing fall and after extensive evaluation he was diagnosed as having Scheuermann’s Kyphosis. His chronic thoracic back pain with underlying Scheuermann's Kyphosis could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The MEB identified Scheuermann’s Kyphosis and forwarded it as the only condition for Informal Physical Evaluation Board (IPEB) adjudication. The IPEB adjudicated the chronic thoracic back pain secondary to Scheuermann's Kyphosis as unfitting, rated 10% citing characteristic pain on motion, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI appealed to the Formal PEB (FPEB) that adjudicated the condition as chronic thoracic back pain with underlying condition of Scheuermann's Kyphosis, and added the VASRD code for residuals of vertebral fractures but applied the same rating rational. The CI was medically separated with a 10% disability rating. CI CONTENTION: “I appealed the decision twice, however board was reluctant to award, 30% despite being rated 60% VA! Addendum for MEB was never seen or addressed; Special Forces Col. on Board (MEB) did not believe injuries were caused by airborne operations. He asked several questions not related to injuries. Did not like Rangers. MEB did not take into account erectile dysfunction (ED) issues with wife. The Army sent me to MEB for hearing loss as well.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The unfitting chronic thoracic back with Scheuermann's Kyphosis condition meets the criteria prescribed in DoDI 6040.44 for Board purview and it is addressed below. The other requested conditions, ED and hearing loss, are not within the Board’s purview. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service FPEB – Dated 20011127 VA (~1 Mo. Post-Separation) – All Effective Date 20020412 Condition Code Rating Condition Code Rating Exam Chronic Thoracic Back Pain w/ Scheuermann's Kyphosis 5285-5299 5295 10% Scheuermann’s Disease of The Thoracic Spine 5285-5291 10%* 20020304 .No Additional MEB/PEB Entries. Lumbar Strain with Degenerative Joint Disease 5292-5010 10% 20020304 Cervical Spine Strain 5290-5010 10% 20020304 Tinnitus 6260 10% 20020312 Depression 9403 10% 20020312 Gastroesophageal Reflux Disease 7346 10% 20030811 0% x3/Not Service-Connected 0 Combined: 10% Combined: 60% *changed to 20% based on VA C&P exam dated 20030811 effective 20020412 ANALYSIS SUMMARY: The Board acknowledges the CI’s contention that suggests ratings should have been conferred for other conditions documented at the time of separation. The Board wishes to clarify that it is subject to the same laws for disability entitlements as those under which the Disability Evaluation System (DES) operates. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. However the Department of Veterans Affairs (DVA), operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service- connected conditions and to periodically reevaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. The Board also notes acknowledges the CI’s assertions that “addendum for MEB was never seen or addressed; Special Forces Col. on Board (MEB) did not believe injuries were caused by air borne operations. He asked several questions not related to injuries. Did not like Rangers.” It is noted for the record that the Board has neither the jurisdiction nor authority to scrutinize or render opinions in reference to asserted improprieties in the disposition of a case. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. It must also judge the fairness of PEB fitness adjudications based on the fitness consequences of conditions as they existed at the time of separation. Chronic Thoracic Back Pain with Scheuermann's Kyphosis Condition. There were two goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. The MEB addendum prepared 5 months prior to separation contained ROM measurements that were requested by the PEB as the original narrative summary (NARSUM) did not contain any ROM measurements. These ROM measurements were of the thoracic spine only and were available to the FPEB. Thoracic Spine ROM NARSUM 10.5 Mos. Pre-Sep Utilized by PEB MEB Addendum 5.5 Mos. Pre-Sep Utilized by FPEB PT ROMs 6 Mos. Pre-Sep Thoracic Spine only ROMs VA C&P 1 Mo. Pre-Sep Lumbosacral Spine ROMs Flexion No ROM measurements 10° (~50% decrease in ROM)* 60° Ext 30° (~75% decrease in ROM)* 20° R Lat Flex 20° (~25% decrease in ROM)* 40° L Lat Flex 20° (~25% decrease in ROM)* 40° R Rotation 25°(normal)* 35° L Rotation 25°(normal)* 35° Combined - 230° Comment Capable of bending Non-antalgic gait Sitting forward to avoid hyperextension of thoracic spine due to pain + tenderness to palpation mid-thoracic area No palpable spasm Normal STR & DTRs + Tenderness to palpation Kyphosis changed only 15° rigid deformity T6-T9 no spasm non-antalgic gait Normal STR & DTRs Upright posture & steady gait No tenderness to palpation + painful motion with flex & ext Normal STR & DTRs § 4.71a (7–1–01 Edition) 10%(painful motion-PEB) 10% (Mod. limited motion-FPEB) 20%(VA) *Percent decrease was documented by the physical therapist who obtained the ROM values The NARSUM prepared 10 months prior to separation noted that the CI had chronic mid- thoracic back pain after he performed a parachute jump with injury in 1996. He did not report any adolescent back pain. He noted some abnormal positioning of his thorax and did not believe it has worsened with time. He reported no radicular symptoms, weakness, or bowel and bladder symptoms. He had no headaches, shoulder pain or paresthesias. He had been followed by an orthopedic surgeon and plain films revealed a mild Kyphosis with anterior wedging of the thoracic vertebrae, Schmorl's nodes and mild Kyphosis, over three segments. The radiographs also revealed endplate irregularity. All of this was consistent with Scheuermann's Kyphosis. Despite this, he had no history of adolescent back pain. The CI was teaching and prolonged standing or sitting caused severe mid-thoracic back pain. He did not have any pain radiating around to the front of his chest as seen if an inter-costal nerve was impinged. He had to avoid running, jumping, jogging and heavy lifting activities due to the pain. Physical exam data is summarized in the chart above. X-ray data was significant for plain film X- rays noted that at the level of T6, 7, and 8, he had greater than 20 degrees of Kyphotic deformity over these three segments. These show endplate irregularity, Schmorl's nodes, anterior wedging and narrowing of the intervertebral disk space. The magnetic resonance imaging revealed a T6-7 paracentral disk bulge that did push on the cord posteriorly. This did not cause significant impingement. There was another bulge at T10-11 which did not appear to contribute to any impingement. His neural foramina were widely patent. There were Schmorl's nodes defects noted to the inferior endplates throughout the thoracic spine. His CT scan confirmed mild anterior wedge compression deformity of T7 and T8 along with the above abnormalities. The CI stated he had a constant ache that was seven out of 10 in his mid- thoracic spine. At least once a week this was exacerbated with some activity that caused it to become 10/10 and knife-like in the same region. Any activity exacerbated his pain and the only thing that relieved it was lying down. The pain began immediately with the onset of running and increased in severity as the duration of the run increased. He was able to walk, but this also increased his pain. He was able to lift up to 50 pounds. He was not using any medications at that time. His diagnosis appeared to be Scheuermann's Kyphosis. It met the radiographic criteria. It was not progressive, for the entire amount of Kyphosis of the thoracic spine was only in the order of 50 degrees. However, it did meet the criteria for Kyphosis over 5 degrees at 3 sequential vertebrae and could remain painful. There was no concern about progression of the Kyphosis, but this was a painful entity and interfered with his Army activities. The CI found no relief with medications. The MEB addendum, prepared 9 months prior to separation, was performed specifically to detail the functional limitations of the CI. It contained similar historical and symptomatic information as the NARSUM above with the following additional items. The CI had no symptoms as an adolescent and only during his jump status did he begin to experience these symptoms. His symptoms were steadily progressive throughout his jump status until they arrived at his present level of disability. He had not previously used narcotics as it interfered with his driving and teaching but at the time of this addendum, he was using narcotics 4 times a day for pain relief. He had to change jobs and could only teach due to the interference with his physical requirements of combat medic. He was unable to run due to the severity of the pain. He could walk only for a very short period, again 15 minutes, before the pain was excruciating and required him to lie down. Lying down was the only thing that relieved his pain. He was not experiencing radicular symptoms. When he woke in the morning, he had tremendous spasm from the bottom of his cervical spine down through the interscapular area. His rhomboid muscles had to be stretched with a shoulder, chest and neck stretch. This pain could be rated as severe as it had significantly limited his activities of daily living. He had tremendously changed his recreational activities due to the limitations this pain caused. It interfered with sleep every night and required him to take a muscle relaxer to relieve the muscle spasm. An additional MEB addendum, prepared 5 months prior to separation, was utilized by the FPEB. The CI appeared in front of the FPEB who then recessed Board proceedings to obtain additional information. The addendum was requested specifically to obtain formal ROM measurements of the thoracic spine along with documenting the presence of paraspinal muscle spasm. It detailed a similar history to the NARSUM and the physical exam findings are also summarized in the chart above. This addendum contained the following significant additional comments: the spine specialist did remark that Scheuermann's disease is not painful in and of itself and it was believed that the CI’s airborne status was the reason for his pain. There was a study that did report that patients with Scheuermann's Kyphosis had more intense back pain, their jobs tended to have lower requirements for activity and they did have less ROM with extension. The examiner opined that Scheuermann’s Kyphosis in and of itself can become painful, but the CI did not have any pain, by his own report, and there is none documented until well after his airborne activities, which would certainly have increased the axial load of the entire spine and could contribute to his spinal pain. At the MEB exam accomplished 2 months prior to separation, the CI reported difficulty with breathing deeply during flare-ups of his back pain. He also reported “Arthritis, thoracic spine; compression fracture thoracic spine; numbness in both hands during back flare up and spine pain.” The MEB physical exam noted decreased ROM in the lumbosacral spine spine, decreased flexion and increased spasm in the lumbosacral area. At the VA Compensation and Pension performed a month prior to separation, the CI reported upper back pain that began in 1996; during an airborne jump. He stated that he had an aching in his upper back and was seen by a physician who prescribed Motrin. He did not have any X- rays until 1997. He reported that there was an aching in his upper back with standing for more than 20 minutes or with running and he currently used muscle relaxants on an as-needed basis. The physical examination findings are summarized in the chart above. The Board directs attention to its rating recommendation based on the above evidence. The PEB disability description was chronic mid-back pain secondary to Scheuermann’s Kyphosis; it applied the analogous code of 5299-5295 and rated the disability at 10%. The FPEB adjudicated this condition as chronic thoracic back pain with underlying Scheuermann’s Kyphosis, coded it analogously as 5285-5299-5295 and rated it 10% based on lumbosacral strain with characteristic pain on motion. This analogous coding and rating scheme was not optimal as the VASRD in effect at the time of adjudication had coding and rating options specifically for the dorsal (thoracic) spine which was the spinal segment responsible for the CI’s disability. It would be more accurate to use VASRD code 5291 for limitations in motion of the dorsal spine as seen in this case. The rating guidelines for the 5291 code include the subjective designations of mild, 0%, and moderate or severe, either resulting in a 10% evaluation. The Board agrees with the FPEB’s adjudication of a moderate limitation in thoracic spine flexion. The FPEB’s use of VASRD code 5285 (Vertebra, fracture of, residuals), did identify a ratable condition, but the final 10% disability rating did not reflect the proper application of VASRD guidelines for that code. The rating guidelines for VASRD code 5285 states, “In other cases rate in accordance with definite limited motion or muscle spasm, adding 10% for demonstrable deformity of vertebral body.” The VA applied the analogous code of 5285-5291 for Scheuermann’s disease of the thoracic spine and initially rated it 10% citing moderate or severely limited motion of the dorsal spine or residuals of compression fracture to include painful and limited motion. The VA rating was later changed to 20% with the same effective date for a moderate loss of motion, a 10% rating, plus an additional 10% rating for the residual compression deformity of the thoracic spine as required by VASRD code 5285. This rating change by the VA reflected a refinement of their rating as opposed to a worsening of the CI’s condition. The CI had a definite limitation in motion of his thoracic spine as evidenced by the MEB addendum’s thoracic spine ROM values. The physical therapist who documented these ROM values also documented the percent decrease from the normal thoracic spine ROM as summarized in the ROM chart above. The CI did not have any palpable spasm. He did have mild anterior wedge compression deformity of two thoracic vertebral bodies warranting application of VASRD code 5285, thus adding 10% to the 10% rating for the moderately limited thoracic spine ROM. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board recommends a disability rating of 20% for the chronic thoracic back pain with underlying Scheuermann's Kyphosis condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the chronic thoracic back pain with underlying Scheuermann's Kyphosis condition, the Board unanimously recommends a disability rating of 20%, coded 5285- 5291 IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Chronic Thoracic Back Pain with underlying Scheuermann's Kyphosis 5285-5291 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120607, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXX, AR20130003829 (PD201200723) 1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl XXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)