RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201014 SEPARATION DATE: 20030630 BOARD DATE: 20130222 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (91W/Medical Specialist), medically separated for chronic low back pain (LBP). His lumbosacral symptoms, initially intermittent, but eventually constant, did not improve with conservative therapy, and his condition could not be adequately rehabilitated in order for him to meet the physical requirements of his Military Occupational Specialty or to satisfy physical fitness standards. He was issued a permanent L3/E2 profile and referred for a Medical Evaluation Board (MEB). The Physical Evaluation Board (PEB) adjudicated the low back condition as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). Additionally, bilateral lower extremity varicose veins, left varicocele, pes planus and vision defect, identified in the rating chart below, were also identified and forwarded by the MEB as conditions which met retention standards and were determined to not be unfitting. The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: “I have to take medication for my back to relieve the pain. I believe these medications are causing seizures which makes driving impossible. These medications are oxycodone, Xanax, Ambien, Adderall and Prozac. I take Prozac for depression.” The CI elaborated no specific contention in his application. 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 varicose veins, varicocele, pes planus and vision defect conditions were not alluded to in the application, and are not judged to have been requested; e.g., they do not satisfy scope requirements. The other conditions (seizures and depression) 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 IPEB – Dated 20030528 VA (1 Mos. Post-Separation) – All Effective Date 20030701 Condition Code Rating Condition Code Rating Exam Low Back Pain/DDD 5295 10% DDD Lumbar Spine 5010-5292 20% 20030724 BLE varicose vein Not Unfitting Varicose Veins LLE 7120 10% 20030724 Varicose Veins RLE 7120 10% 20030724 Varicocele Not Unfitting Varicocele 7599-7120 NSC 20030724 Vision Defect Not Unfitting Bilateral Peripheral Retinal Deg 6099-6011 0% 20030724 Pes Planus Not Unfitting B Pes Planus 5276 NSC 20030724 .No Additional MEB/PEB Entries. 0% X 1 / Not Service-Connected x 3 20030724 Combined: 10% Combined: 40% ANALYSIS SUMMARY: Chronic Low Back Pain Condition. The MEB narrative summary (NARSUM) notes intermittent and recurrent LBP during a previous enlistment. Shortly after re-enlistment, he reported LBP, without antecedent trauma, on 18 May 2001, which flared intermittently. Pain gradually became constant. Magnetic resonance imaging (MRI) performed on 11 October 2002 revealed degenerative disc disease (DDD) at L4 through S1, and a L5 posterolateral disc protrusion contacting the left L5 nerve root. Pain specialist 9 December 2002 read the MRI as normal. Surgery was not recommended. Treatment including chiropracty, medications, physical therapy and therapeutic injections, provided only brief and transient relief. Service treatment records (STRs) reveal periodic visits for LBP, exacerbated by mild activity, such as lifting tent poles or twisting, and without radiation of symptoms suggesting radiculopathy. There is no documentation of any incapacitating episodes. There were two goniometric range-of-motion (ROM) examinations with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, as summarized in the following chart: Thoracolumbar ROM (Degrees) MEB ~3 Mo. Pre-Sep (20030326) VA C&P ~<1 Mo. Post-Sep (20030724) Flexion (90 Normal) 75 80 Extension (30) 15 10 R Lat Flex (30) 25 30 L Lat Flex (30) 20 30 R Rotation (30) 25 - L Rotation (30) 25 - Comment Tender to pressure; without palpable spasm; no visible deformity Pain w/extension Gait normal SLR negative Strength normal §4.71a Rating 10% 10% At the MEB exam, the CI reported constant LBP, aggravated by running, bending, lifting, twisting, and standing longer than 30 minutes. His pain was exacerbated with lumbar extension and intermittently was relieved by sitting or lying down, and was accompanied by no radicular symptoms. He had been prescribed non-narcotic and narcotic analgesic medications. The MEB physical exam 26 March 2003 noted that a physical examination revealed tenderness to pressure (TTP) at the lumbosacral junction, without evidence of muscles spasm, weakness or sensory deficit. ROM is recorded in the chart. At the VA Compensation and Pension (C&P) exam on 24 July 2003, the CI reported pain “at the top of his buttocks,” especially after standing for long periods. Upon examination, the straight leg raising (SLR) test was negative, strength testing was normal and no sensory abnormalities were noted. ROM on this occasion is recorded above. Gait was not recorded but at the 6 August 2003 C&P examination 2 weeks later, gait was reported as 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 2003 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, and its applicable diagnostic codes including 5292 (limitation of lumbar spine motion), 5293 (intervertebral disc syndrome) and 5295 (lumbosacral strain). The PEB rated the back pain condition 10% coded 5295, lumbosacral strain. The VA rated his condition at 20%, coded 5010-5292, citing moderate limitation of lumbar motion. The Board first considered the rating under code 5292 (limitation of lumbar spine motion). All Board members agreed the limitation of motion on both examinations did not approach the moderate level and more nearly approximated the slight level with a 10% rating. Since the CI’s diagnosis at the MEB had been “herniated nucleus pulposus,” the Board then considered whether a higher rating would be warranted under the Rating Code 5293 “Intervertebral Disc Syndrome.” Although there was documented disc disease, there were no signs, symptoms or objective findings for radiculopathy. Additionally, there was no documentation of incapacitating episodes to support a minimum rating under the 5293 code guidelines in effect at the time of separation. Finally, the Board considered the rating under the VASRD diagnostic code 5295 used by the PEB. All members agreed that the symptoms and examination, including ROM, supported a rating of 10%, but concluded that the preponderance of evidence did not support a higher rating than the 10% assigned by the PEB. 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 lumbosacral 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. In the matter of the lumbar spine 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 Lumbar Spine: Herniated Nucleus Pulposus 5295 10% RATING 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120610, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review