RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201561 SEPARATION DATE: 20020830 BOARD DATE: 20130201 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Soldier, SGT/E-5(77F/Petroleum Supply Specialist), medically separated for mechanical low back pain (LBP). The CI noted back pain in February 1997 after playing basketball while stationed in Germany. Despite numerous physical therapy (PT) sessions, a selective nerve root block (SNRB), and epidural steroid injection, the CI did not improve adequately to meet the physical requirements of his Military Occupational Specialty (MOS). He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded LBP as medically unacceptable IAW AR 40-501. The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the mechanical LBP as unfitting, rated 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: 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. 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 20020516 VA (4 Mos. Post-Separation) – All Effective Date 20020831 Condition Code Rating Condition Code Rating Exam Mechanical Low Back Pain 5295 10% Mechanical Low Back Pain 5295 10% 20021220 .No Additional MEB/PEB Entries. Migraine Headaches 8100 10% 20021220 0% X 0 / Not Service-Connected x 2 20021220 Combined: 10% Combined: 20% ANALYSIS SUMMARY: Mechanical Low Back Pain. The CI had a history of chronic LBP starting in 1997 which did not improve with non-surgical interventions and physical therapy. X-ray examination performed in August 2001 demonstrated mild degenerative disc disease (DDD) from L4-S1. A magnetic resonance imaging (MRI) scan, performed on 28 September 2001, revealed a moderate central disc protrusion at L4-L5 causing moderate spinal stenosis and a disc bulge at L5-S1 without stenosis. The CI underwent nerve root block and steroid injections, 18 October 2001, resulting in no improvement. The MEB narrative summary (NARSUM), performed on 28 March 2002, reported that the CI continued to experience intermittent LBP (4/10 on the pain scale) and lower extremity pain with prolonged standing and walking. The pain typically was relieved by sitting for 10-15 minutes. These episodes were occurring approximately twice a week. The CI however denied any pain with activities that involved running or sitting. The CI reported that surgical intervention was offered but he declined it. The CI was not using daily medications at that time. On examination, there was no tenderness on palpation. Range-of-motion (ROM) was normal without pain (flexion 90 degrees, extension 30 degrees, lateral bending 35 degrees both sides, rotation 30 degrees). There was no deformity of the spine. Muscle strength, reflexes, and sensation were normal in both lower extremities. There was no pain with the straight leg raising (SLR) and no signs of radiculopathy. The CI had a normal gait and completed tandem walking without difficulty. On 20 April 2002, the CI passed his Army physical fitness test performing 78 push-ups, 89 sit-ups, and running the 2 mile run in 13 minutes, 20 seconds. The VA Compensation and Pension (C&P) examination, approximately 4 months after separation, the CI reported that he continued to have sharp LBP with sitting or standing for periods longer than an a few hours. This occurred two to three times a week but was relieved with rest and occasionally Motrin. He denied any bowel or bladder incontinence. There were no significant soft tissue or bony deformities noted on examination. There was no tenderness with palpation, no spasms noted, and no signs of radiculopathy. The trunk ROM was reported as within normal limits with no limitation due to pain. There was no evidence of weakness or sensory deficit in the lower extremities. X-rays of the spine, 20 December 2002 demonstrated well preserved alignment of the spine. The vertebral bodies and disc spaces were normal in height. The Board directs attention to its rating recommendation based on the above evidence. 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. 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 must correlate the above clinical data with the 2002 VASRD standards for the spine (applicable diagnostic codes include 5292 limitation of lumbar spine motion; 5293 intervertebral disc syndrome; and 5295 lumbosacral strain). The PEB rated the condition 10% citing characteristic pain on motion consistent with rating using the lumbar strain code 5295. The VA rated also rated the condition 10% using the same code (5295). The Board first considered the rating under 5295, lumbosacral strain and noted the MEB and C&P examinations did not report characteristic pain on motion to support the 10% ratings adjudicated. There were no findings to support a higher rating under this code such as demonstrable muscle spasm on forward bending; loss of lateral spine motion, unilateral, in standing position. The Board next considered the rating under code 5292 for limitation of lumbar spine motion. Both the MEB and VA examinations report that the ROM of the patient’s lumbar spine was normal. The MEB NARSUM ROM was detailed and goniometric and was completely normal without any limitation. The Board concluded there was no compensable limitation of motion. The Board finally considered the rating under the code 5293 for intervertebral disc syndrome. The use of code 5393 requires persistent or recurring attacks of sciatic neuropathy (with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings). The CI’s condition when he first presented in was consistent with intervertebral disc syndrome. However, both the MEB and C&P examinations were negative for signs or symptoms of intervertebral disc syndrome and therefore code 5293 would not be applicable. There was no evidence of an unfitting radiculopathy for consideration of a separate rating for peripheral nerve impairment. The Board considered the report of pain with prolonged standing or walking and pain with strenuous activities and concluded the 10% rating adjudicated by the PEB and VA was supportable with consideration of §4.40, functional loss. However, no route to a higher rating was found. 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 mechanical low back 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 mechanical lower back 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 Mechanical Low Back Pain 5295 10% RATING 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120830, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxx, AR20130003927 (PD201201561) 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)