RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201549 SEPARATION DATE: 20030828 BOARD DATE: 20130402 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Duty PFC/E-3 (98G10/Linguist [in training]), medically separated for chronic low back pain (LBP) without radicular signs and chronic bilateral shin splints. The CI initially sought care for bilateral leg pains in October 2001 after walking. The CI’s LBP began in October 2002 and was felt to be related to the shin pain. The CI could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L4 profile and referred for a Medical Evaluation Board (MEB). The MEB also identified and forwarded mild pes planus, identified in the rating chart below, as meeting retention standards. The PEB adjudicated the chronic LBP without radicular signs and chronic bilateral shin splints as unfitting, rated 10% and 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining condition was determined to be not unfitting and not ratable. The CI made no appeals and was medically separated. CI CONTENTION: “I was discharged based on a general/broad diagnosis of chronic pain. The cause of the pain was not determined until later by a VA doctor who diagnosed the pain as Fibromyalgia. This is what causes the pain and it was triggered by my service. I receive ongoing medical treatment because there is no known cure. Fibromyalgia causes daily pain in all areas of my body and affects my ability to lead a normal active life. I take medication on a daily basis to treat the pain. The diagnosis and rating I received at my time of discharge were not accurate or detailed and do not reflect the actual percent I am disabled and the affect it has on my life. Fibromyalgia affects everything I do on a daily basis and I am in constant pain.” SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. Ratings for unfitting conditions will be reviewed in all cases. The chronic LBP and chronic bilateral shin splints conditions meet the criteria prescribed in DoDI 6040.44 for Board purview and are addressed below. The requested condition of fibromyalgia is 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 20030715 VA (1 Mos. Post-Separation) – All Effective Date 20030829 Condition Code Rating Condition Code Rating Exam Chronic LBP w/o Radicular Signs 5299-5295 10% Chronic LBP 5237 10% 20030930 Chronic B/L Shin Splints 5099-5022 0% B/L Shin Splints 5099-5022 NSC* 20030930 Lt Tibia Stress Fracture 5262 NSC* 20030930 Mild Pes Planus Not Unfitting No Corresponding VA Entry .No Additional MEB/PEB Entries. 0% X 0 / Not Service-Connected x 2 (includes above) 20030930 Combined: 10% Combined: 10% *Per VARD dated 20040105. ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. 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. 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 nor for conditions determined to be service-connected by the VA but not determined to be unfitting by the PEB. However the Department of Veteran 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 re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should his degree of impairment vary over time. 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. Chronic Low Back Pain without Radicular Signs Condition. The CI started complaining of significant LBP in October 2002. The pain was accompanied by tightness in the lumbar area and exacerbated by prolonged standing, sitting, twisting, and bending. Both the X-ray exam from 15 January 2003 and magnetic resonance imaging (MRI) exam from 3 February 2003 were negative for any lumbosacral spine pathology. Treatment including physical therapy (PT) was not useful in alleviating the back pain. A permanent profile was assigned because the CI could not perform any Army physical fitness tests or strenuous physical activity, and a MEB was recommended. The MEB narrative summary (NARSUM) from 11 June 2003, 6 weeks prior to separation, noted the CI reported constant pain, rated higher on the left side, radiating upward the thoracic spine and periodically to the right leg. She stated the pain was alleviated for short periods of time by heat, ice, stretching and lying down. The physical exam noted full range-of- motion (ROM) accompanied by pain and tenderness to palpation bilaterally in the sacroiliac joints and paraspinal muscles, accentuated on the right side. There was no evidence of abnormal contour. On 30 September 2003, at the VA Compensation and Pension (C&P) examination, a month after separation, the CI reported continued back pain, radiating to the right shoulder, hips, buttocks and hamstrings bilaterally. The CI rated the pain greater on the right side, sharp in nature and exacerbated by increased activity. On examination the CI was in no apparent distress and had a normal gait and posture. ROM of the lumbosacral spine was described as “perfectly normal” and not painful. Deep tendon reflexes (DTR) were 2+, symmetrical, with a normal motor and sensory exam, and negative straight leg raising (SLR) bilaterally. The examiner could not elicit any radiculopathy signs and diagnosed her condition as functional LBP. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the CI’s back pain condition at 10%, coded 5299-5295 (lumbosacral strain) using the 2002 VASRD guidelines in effect at that time. The VA rating decision dated 16 October 2003 assigned a 10% disability based on the current VASRD rating guidelines for diseases and injuries of the spine, (coded 5237) citing functional loss secondary to pain. These §4.71a rating criteria became effective in September 2003, a month after the CI separated. In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation, therefore the Board considered the rating recommendation based on application of codes 5292 (limitation of motion), 5293 (intervertebral disc syndrome), and 5295 (lumbosacral strain). No rating could be assigned considering codes 5292 and 5293 as there was no limitation of motion or intervertebral disc syndrome. No higher rating could be assigned under the lumbosacral strain code, 5295, as there was no muscle spasm or loss of lateral spine motion, unilateral, in a standing position. There was also no evidence of radiculopathy that would justify increasing the rating. 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 LBP without radicular symptoms condition. Chronic Bilateral Shin Splints. The narrative summary (NARSUM) noted the CI started complaining of bilateral leg pain in October 2001. The pain was localized to the tibia region, exacerbated by walking and climbing stairs, and was not alleviated by PT and orthotics. While lower extremities X-ray exam from February 2002 was normal, bone scan from 7 March 2002 noted mild periostitis of mid and distal tibias, greater on the right side, most compatible with shin splints. PT evaluation noted the CI had genu valgus and mild pes planus (both developmental characteristics) and it was considered that the strain of her tibias were secondary to a biomechanical factors. PT notes from 22 March 2002 to 8 January 2003 noted recurring shin pain with running and physical training. At the time of the MEB NARSUM examination 11 June 2003, there was tenderness to palpation bilaterally over the proximal medial tibias. ROM of the lower extremities was normal with normal gait with normal vascular, sensory and motor exam. At the VA C&P examination on 30 September 2003, a month after separation, there was normal motor and sensory function of the lower extremities with slight tenderness to palpation over the tibiae and no symptoms related to the previous suspicion of left tibia stress reaction/shin splints. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the condition 0% coding analogously to periostitis (5099-5022). The VA denied service-connection (and consequently rating) for the left tibia fracture and bilateral shin splints citing no evidence of a chronic disability related to service. Although the CI experienced shin splint pain with the vigorous physical activity associated with military training, the examinations proximate to separation including the MEB NARSUM and VA C&P examinations evidenced only mild tenderness with normal gait. 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 bilateral shin splints 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 LBP without radiculopathy condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the chronic bilateral shin splints 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 Low Back Pain without Radiculopathy 5299-5295 10% Chronic Bilateral Shin Splints 5099-5022 0% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120816, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxx, AR20130009595 xxxxxxxxxxxxxxx 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 xxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)