RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200938 SEPARATION DATE: 20030430 BOARD DATE: 20130129 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (54B/Chemical Operations Specialist), medically separated for chronic low back pain (LBP) due to multi-level degenerative disc disease (DDD) of the lumbosacral spine. He did not improve adequately with treatment and was unable to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a L3 Profile and referred for a Medical Evaluation Board (MEB). Plantar fasciitis, retropatellar pain syndrome (RPPS), obesity and meralgia paresthetica conditions, identified in the rating chart below, were also identified and forwarded by the MEB. The Physical Evaluation Board (PEB) adjudicated the chronic LBP condition as unfitting, rated 10% with likely application of US Army Physical Disability Agency (USAPDA) pain policy. The remaining conditions were determined to be not unfitting or not ratable (in the case of obesity). The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: “My medical condition has gotten worse and am becoming limited to daily activities”. 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 rated condition chronic LBP due to multi-level DDD of the lumbosacral spine is the only condition that 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 20030114 VA (1 Mo. Pre-Separation) – All Effective Date 20030501 Condition Code Rating Condition Code Rating Exam Chronic Low Back Pain 5295 10% Lumbar Spine Degen. Disc Dis. 5293-5292 40% 20030401 Retropatellar Pain Syndrome Not Unfitting Lt Knee Retropatellar Pain 5099-5014 10% 20030401 Rt Knee Retropatellar Pain 5099-5014 10% 20030401 Plantar Fasciitis Not Unfitting Bilateral Plantar Fasciitis 5299-5276 10% 20030401 Meralgia Paresthetica Not Unfitting NO VA ENTRY Obesity Not a Ratable Condition NO VA ENTRY .No Additional MEB/PEB Entries. 0% X 1 Combined: 10% Combined: 60% ANALYSIS SUMMARY: Chronic Low Back Pain Due to Multi-level Degenerative Disc Disease of the Lumbosacral Spine Condition. The MEB narrative summary (NARSUM), dictated 28 August 2002, noted chronic intermittent LBP since a motorcycle accident in 1998 and aggravated by a subsequent motor vehicle accident in January 2001. He returned to duty but continued to complain of back pain aggravated by standing, walking, repeated bending, running and heavy lifting. Computed axial tomography (CAT) scan in December 2002 demonstrated multilevel degenerative lumbar disc disease with disc protrusion at several levels but no herniation. Conservative treatment was not helpful however surgery treatment was not considered necessary. An assessment on 27 March 2002 noted chronic pain with a normal examination including flexion and gait. A physical therapy evaluation on 19 August 2002 noted painful motion with moderately limited motion (flexion 40 degrees, extension 10 degrees, lateral flexion 20 degrees both sides, and rotation 20 degrees both sides). Gait, posture, muscle strength and reflexes were normal. An orthopedic examination performed on 28 August 2002 also noted normal gait, passive flexion of 90 degrees and extension of 20 degrees. The MEB physical examination on 30 October 2002 (DD Form 2808) recorded diffuse tenderness to pressure on the thoracolumbar spine region, no muscle spasms or deformity. Range -of-motion (ROM) was moderately limited by pain (flexion 45 degrees, extension 20 degrees, lateral flexion 25 degrees both sides). Leg raising increased back pain without radicular symptoms. Reflexes were intact. Neurological examination was normal except for decreased sensation in the outer right thigh consistent with a possible L4 nerve root dysfunction versus meralgia paresthetica (lateral femoral cutaneous nerve compression at the waist unrelated to back condition). The MEB NARSUM dated 20 December 2002 cited the October 2002 MEB examination. At the VA Compensation and Pension (C&P) examination, performed on 1 April 2003, a month prior to separation, the exam of the lumbar spine revealed no asymmetry, deformity or focal tenderness or muscle spasms. Gait was normal. ROM was limited to 30 degrees flexion, 20 degrees extension, 15 degrees lateral flexion bilaterally. Pain was reported with all directions of motion. Lower extremity muscle strength and reflexes were normal. The Board directs attention to its rating recommendation based on the above evidence. In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation. The Board notes that the 2002 Veteran Administration Schedule for Rating Disabilities (VASRD) standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004. The Board must correlate the above clinical data with the 2003 rating schedule (applicable diagnostic codes include: 5292 limitation of lumbar spine motion; 5293 intervertebral disc syndrome; 5295 lumbosacral strain). The PEB rated the CI’s back pain condition at 10%, coded 5295 (lumbosacral strain) citing pain with motion without spasm (but also noted moderate limitation of motion). The VA rated the back condition 40% (coded 5293-5292) citing severe limitation of motion at the time of the C&P examination. The Board considered the rating under the VASRD diagnostic code 5292, limitation of lumbar motion. The Board agreed that the ROM documented at the time of the MEB examination supported the 20% rating, moderate, under the VASRD diagnostic code 5292. The Board noted the worsened ROM at the time of the C&P examination; however it was not consistent with previous examinations or the absence of spasm, and was otherwise unexplained by any cause for worsening. The CI had a chronic condition, and the preponderance of evidence more nearly approximated the moderate limitation than the severe. The Board next considered whether a higher rating was warranted under the guidelines for intervertebral syndrome, code 5293, however there were no incapacitating episodes to support a minimum rating under this code. The Board also considered the rating under the code, 5295, lumbosacral strain but concluded the preponderance of evidence did not support a rating higher that the 10% rating assigned by the PEB. There was characteristic pain on motion but no muscle spasm, or unilateral loss of lateral motion, or evidence of severe strain with listing or marked limitation of motion. There was no evidence of ratable peripheral nerve impairment which would provide for additional or higher rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic LBP condition coded 5292. 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. In the matter of the chronic LBP condition, the Board unanimously recommends a disability rating of 20% coded 5292 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 Low Back Pain 5293-5292 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120604, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXX, AR20130003831 (PD201200938) 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 XXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)