RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200982 SEPARATION DATE: 20030325 BOARD DATE: 20130220 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (77F20/Petroleum Supply), medically separated for chronic right thoracolumbar myofascial pain. The CI had a history of right-sided back pain which began during field training in March 2001, with no associated trauma. The back condition could not be adequately rehabilitated. The CI did not improve adequately with treatment to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the chronic back pain condition as unfitting, rated 10% with application of the Department of Defense Instruction (DoDI) 1332.39 and Army Regulation 635-40, and the likely application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: “still has daily pain (chronic), change of lifestyle, change of jobs (resulting to less income)” 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. 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 IPEB – Dated 20030224 VA (7 Mos. Post-Separation) – All Effective Date 20030326 Condition Code Rating Condition Code Rating Exam Chronic Rt Thoracolumbar Myofascial Pain 5299-5295 10% Myofascial Pain Syndrome Thoracolumbar Area 5021-5237 10%* 20031020 No Additional MEB/PEB Entries 0% X 0 / Not Service-Connected x 1 20031020 Combined: 10% Combined: 10% *Rating increased to 20% ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which his service-incurred condition continues to burden him. The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws (Title 38, United States Code). The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. Chronic Right Thoracolumbar Myofascial Pain. The 2003 Veterans Affairs Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004, and were identical to the 2003 VASRD standards used by the VA in its initial rating decision. IAW DoDI 6040.44, this Board must consider the appropriate rating for the CI’s back condition at separation based on the VASRD standards in effect at the time of separation. The narrative summary (NARSUM), completed on 27 December 2002, 3 months prior to separation, noted weekly back spasms requiring large doses of muscle relaxant or anti-inflammatory medications. Trigger points in her right paraspinal musculature were treated with steroid injections without benefit. The CI reported constant, moderately severe, aching pain. The pain was worse in the morning; caused difficulty sleeping and sitting up; and increased with sitting or standing for more than 15 minutes. There was no radiation of pain to the legs, lower extremity weakness, numbness or tingling, or bowel or bladder incontinence. The physical exam noted spasm with palpation of the low back; tenderness to palpation (TTP) of the right paraspinal area from T11 to L2; and palpation of a large trigger point in the same area reproduced the CI’s symptoms. Muscle tone was normal in the lower extremities bilaterally. The straight leg raise (SLR), cross SLR, and reverse SLR tests were negative bilaterally. The facet compression test was positive bilaterally. The Patrick (FABER) and Lewin-Gaenslen (sacroiliac joint) tests were negative. All range-of- motion (ROM) measurements were normal by current standards except for slight decreased rotation. Muscle spasm and painful motion were present. The neurological exam noted intact pin prick and light touch sensation bilaterally; patellar, Achilles, and plantar reflexes were normal bilaterally. The examiner cited a bone scan in September 2002 which reportedly showed no uptake in the thoracolumbar spine. An X-ray in April 2001 showed no scoliosis greater than 10 degrees. At the VA Compensation and Pension exam in October 2003, 7 months after separation, the CI described sharp mid-low back pain. The pain occurred about twice a month with flare-ups, lasted up to hours, and was 6-7/10 in intensity. Her pain was worse with bending, lying down, and lifting more than five pounds. She could walk 2-3 miles without difficulty and without assistive device. She reported no numbness or tingling, or bladder or bowel dysfunction. The examiner noted normal appearance of the thoracolumbar spine, and no tenderness, spasm, or weakness at the time of the exam. There was no apparent scoliosis. The neurological exam noted no sensory or motor abnormalities, and normal deep tendon reflexes, bilaterally. The straight leg test was negative to 70 degrees. The gait was normal. The ROM was normal, with pain at extremes of ROM for forward flexion, right lateral flexion, and right rotation. The examiner cited undated X-rays of the thoracic spine which reportedly showed kyphoscoliosis, without fracture, slippage or disk narrowing; and undated X- rays of the lumbar spine which were reportedly normal. The Board directs attention to its rating recommendation based on the above evidence. The PEB applied code 5299-5295 (Lumbosacral strain) and cited “characteristic pain on motion” as a basis for a 10% rating. The VA’s initial 10% rating decision did not specify a VASRD code under the old spine rules. The VA’s subsequent rating increase to 20% was implemented under new spine codes which were not in effect at the time of separation, and were thus not applicable to the Board’s deliberation. The Board agreed that the 10% criteria were met under the 5295 code, but debated if a higher rating was justified by right-sided paraspinal muscle spasm present at the NARSUM exam. However, loss of lateral spine motion was not present and therefore the next higher 20% criteria were not met under the 5295 code. The Board agreed that there was no route to a higher rating under other spine codes. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic right thoracolumbar myofascial 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. As discussed above, PEB reliance on DoDI 1332.39 and the USAPDA pain policy for rating 5299-5295 was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic right thoracolumbar myofascial pain condition and IAW VASRD §2003 VASRD, 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 Right Thoracolumbar Myofascial Pain 5299-5295 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120611, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXX, AR20130003975 (PD201200982) 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 XXXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)