RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200725 SEPARATION DATE: 20061128 BOARD DATE: 20130402 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (13B/Cannon Crewmember), medically separated for chronic back pain. The CI injured his back in an improvised explosive device (IED) attack during his second deployment to Iraq in May 2005. He was evaluated, treated conservatively and placed on quarters for 2 weeks before returning to his duties. He again injured his back during an abrupt stop while serving in the .50 caliber gunner’s turret. He was treated and received physical therapy. He continued with his unit and re-deployed in early 2006 where we was further evaluated and determined to have a compression fracture. He continued with conservative treatment but was unable to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3S2 profile and referred for a Medical Evaluation Board (MEB). Posttraumatic stress disorder (PTSD), insomnia, subjective memory loss, history of bulimia, history of obesity, hyperlipidemia, chronic intermittent right wrist pain, and bilateral pes planus conditions, identified in the rating chart below were also identified and forwarded by the MEB. The Physical Evaluation Board (PEB) adjudicated the chronic back pain condition as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated with a 10% disability rating. CI CONTENTION: “Disability was underrated existing symptoms at that time deserved a higher rating. Rating of 20% was assigned 2/15/2007 by Denver Colorado Veterans Affairs Regional Office. Currently going for a higher rating as veteran's condition has worsened.” 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 conditions “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The rated condition chronic back pain, as requested for consideration, meets the criteria prescribed in DoDI 6040.44 for Board purview and is addressed below. 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 PEB – Dated 20061004 VA (<1 Month Post-Separation) – All Effective Date 20061001* Condition Code Rating Condition Code Rating Exam Chronic Back Pain 5299-5235 10% Thoracolumbar Spondylosis and Compression Fracture T11 5235 20% 20061205 PTSD Not Unfitting PTSD with History of Mild Concussion Secondary to IED Explosion 9411 30% 20061204 Chronic Intermittent Right Wrist Pain Not Unfitting Tendonitis, Right Wrist 5024 10% 20061205 History of Bulimia Not Unfitting Bulimia Nervosa 9521 0% 20061204 Insomnia Not Unfitting NO VA ENTRIES Subjective Memory Loss Not Unfitting History of Obesity Not Unfitting Hyperlipidemia Not Unfitting Bilateral Asymptomatic Pes Planus Not Unfitting .No Additional MEB/PEB Entries. Sebaceous Hyperplasia of Nose and Dermatitis Face, Neck and Back 7820- 7806 30% 20061205 Combined: 10% Combined: 70% *The VA used an incorrect separation date; the correct separation date would have been 20061128. ANALYSIS SUMMARY: Chronic Back Pain Condition. There were three 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. Thoracolumbar ROM (Degrees) MEB ~3 Mo. Pre-Sep (20060826) p.49 VA C&P 7 Days Post-Sep (20061205)p.165 VA C&P ~12 Mo. Post-Sep (20071213)p.168 Flexion (90 Normal) 45 (65, 46, 43) 65 75 Ext (30) 20 (23, 21, 18) 25 20 R Lat Flex (30) 20 (20, 20, 17) 20 30 L Lat Flex (30) 30 (30, 31, 32) 25 30 R Rotation (30) 30 (23, 23, 36) 30 30 L Rotation (30) 30 (35, 42, 36) 30 30 Combined (240) 175 185 215 Comments Limited by pain No muscle spasm Gait normal Muscle spasm with flexion Painful motion Gait normal §4.71a Rating 20% 10% 10% The CI sustained a back injury in May 2005, while deployed to Iraq, when an IED exploded underneath his vehicle and he was thrown away. The CI reinjured his back a month later when his vehicle hit a large pothole and he was thrown forward. As the back pain increased, physical therapy was recommended and his activities were reduced to “radio watch” only, though he was not placed on a profile and completed his deployment. Following return to his home base, the CI was evaluated in the clinic in February 2006 for his back pain. The CI complained of slight non radiating lower back ache, intermittent and constant dull pain between shoulder blades. On examination there was muscle spasm with normal gait and normal neurologic examination. X-ray exam evidenced mild degenerative changes at the lower thoracic and upper lumbar spine as well as mild to moderate compression changes at T11-T12 and possibly L1 vertebral body. Magnetic resonance imaging (MRI) exam from June 2006 noted compression deformity of the T11 vertebral body and mild degenerative changes at the T11-T12 and T12-L1 levels with no spinal stenosis. A 26 April 2006 clinic examination noted muscle spasm with straightening of lumbar lordosis, but “no loss of range of motion of the back.” A 21 June 2006 clinic exam noted muscle spasm with loss of lordosis. A 14 July 2006 clinic examination recorded back flexion and extension was “normal.” As the pain was not alleviated by conservative treatment, a permanent profile was issued and MEB was recommended. The MEB narrative summary (NARSUM) examination on 29 August 2006, 4 months prior to separation, noted the CI reported constant pain in his mid upper back, radiating into his lower neck and lower back, five out of ten in intensity. He denied any radicular symptoms but acknowledged occasional pain in the posterior/inferior aspect of his right shoulder after increased activity. Physical exam revealed tenderness to palpation around T5-L1 levels with no muscle spasm. Back range-of-motion (ROM) was limited by pain per the chart. At the VA Compensation and Pension (C&P) examination on 5 December 2006, 7 days after separation, the CI continued to complain of upper and lower back pain rated six-seven out of ten without radicular pain, neurologic symptoms of the lower extremities or associated bladder dysfunction. The CI complained of inability to walk for more than 20 minutes or play lacrosse. The examiner mentioned one incapacitating episode of lumbar pain over the previous 12 months with 2 day duration. ROM was limited per the chart. Repetitive movement elicited mid back pain but no fatigability, incoordination or reduction in ROM. The physical exam did not evidence focal tenderness or abnormal spinal contour and gait was normal. On forward bending the examiner noted conspicuous paralumbar muscle spasm and reduced lumbar lordosis. Neurological exam including deep tendon reflexes (DTRs) and muscle bulk and strength was normal. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the back pain condition 10% analogous to code 5235, vertebral fracture or dislocation. The VA rated the thoracolumbar condition under the same 5235 code but assigned a rating of 20% citing flexion of the thoracolumbar spine limited to 60 degrees. While the VA rater assigned a 20% disability rate based on thoracolumbar spine flexion limited to 60 degrees, actual exam notes evidenced that flexion was 65 degrees without further reduction with repetition, which would warrant a disability rating of 10%. While there was muscle spasm with flexion, the examiner’s observation of a loss of lordosis with flexion occurs with normal flexion and indicates normal lumbar spine mobility despite the apparent muscle spasm. The Board noted the limitation of thoracolumbar motion from the MEB NARSUM supported consideration of a 20% rating however examinations in April and July 2006 recorded normal range of motion. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic back pain 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 back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Chronic Back Pain 5299-5235 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120516, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130009556 (PD201200725) 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 and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)