RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200564 SEPARATION DATE: 20030807 BOARD DATE: 20130226 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve SPC/E-4 (92A/Automated Logistical Specialist), medically separated for chronic low back pain (LBP). The CI injured her back in 1990 during her initial enlistment. She remained in the Individual Ready Reserves until 1997 when she returned to drill status. Her pain continued and she underwent an L5-S1 Discectomy in November of 2000. She remained under profile until she was mobilized in January of 2003. Her chronic LBP condition did not improve adequately and she was unable to meet the physical requirements of her MOS or satisfy physical fitness standards. She was issued a L4 Profile and referred for a Medical Evaluation Board (MEB). Left ankle pain and migraine headache 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 application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) under the old spine rules effective 1 July 2003. Although the remaining left ankle pain and migraine headache conditions were listed as existing prior to service (EPTS), they were reviewed by the PEB and determined to be not unfitting. The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: “I initially injured my back during basic training. I now am on SSD for lower back and mental health. I have filed a claim for PTSD which is pending”. 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 chronic LBP condition requested for consideration is the only condition that meets the criteria prescribed in DoDI 6040.44 for Board purview; and, is addressed below. The other requested condition mental health/posttraumatic stress disorder (PTSD) and any peripheral nerve or radiculopathy condition 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 PEB – Dated 20030702 VA (1 Mos. Post-Separation) – All Effective Date 20030808 Condition Code Rating Condition Code Rating Exam Chronic Low Back Pain 5299-5295 10% Lumbar Spine DDD 5243 NSC 20030925 Left Ankle Pain, Posttraumatic Arthritis Not Unfitting Left Ankle, S/P ORIF 5271 NSC 20030925 Migraine Headaches Not Unfitting Migraine Headaches 8100 NSC 20030925 .No Additional MEB/PEB Entries. Chronic Right Rhomboid Spasm 5201 0% 20030925 Combined: 10% Combined: 0%* *VARD dated 20040812 (~1 year post-separation) adjudicated condition(s) as NSC (Not Service Connected, Not Incurred/Caused by Service). No change in combined rating until 2011 ANALYSIS SUMMARY: The 2002 Veterans’ Administration Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine were changed to an interim §4.71a rating standard effective 23 September 2002 and were in effect at the time of the CI’s separation. Seven weeks after her separation, the current VASRD rating standards came into effect on 26 September 2003, including a plate for normal thoracolumbar range-of-motion (ROM), and were used by the VA to adjudicate her case. The 2002 standards for rating are based on the rater’s interpretation and opinion of ROM impairment regarding degree of severity, whereas the current standards specify rating thresholds in degrees of ROM impairment measured with an instrument and following a table. For the reader’s convenience, the 2002 rating codes under discussion in this case are excerpted below. 5292 Spine, limitation of motion of, lumbar: Severe ...................................................................................................................................................40 Moderate ..............................................................................................................................................20 Slight .....................................................................................................................................................10 5293 Intervertebral disc syndrome: With incapacitating episodes having a total duration of at least six weeks during the past 12 months .................................................................................60 With incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months .......................................................................................................40 With incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months .......................................................................................................20 With incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months .......................................................................................................10 Note (1): For purposes of evaluations under 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 5294 Sacro-iliac injury and weakness: 5295 Lumbosacral strain: Severe; with listing of whole spine to opposite side, positive Goldthwaite’s sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion ...................................................................................................................40 With muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position .................................................................................................................................20 With characteristic pain on motion .......................................................................................................10 With slight subjective symptoms only .....................................................................................................0 Chronic Low Back Pain Condition. The narrative summary (NARSUM) notes the CI had LBP that was exacerbated with activity, impact on duty was significant and the CI was unable to perform any vigorous activities. She was unable to pass an Army Physical Fitness Test (APFT) to include the alternative aerobic event of walking. The CI could not carry any weight on her back as this caused excruciating pain. She stated that any deep knee bending or forward-flexion with repetition caused her to be unable to walk the following day. Her Commander’s performance statement indicated profile restrictions and “lack in physical ability” impacting duty performance. The back evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, are summarized in the chart below. Lumbar ROM* Neurologist ~4 Mo. Pre-Sep NARSUM ~2 Mo. Pre-Sep VA C&P ~1 Mo. Post-Sep Flexion 70° 30° Ext 5-10° 10° R Lat Flex 30° 10° L Lat Flex 30° 10° R Rotation 30° 10° L Rotation 30° 10° Combined ---° 80° Comment: Antalgic gait; foot drop Right LE radicular No tenderness to palpation, normal strength, normal reflexes Once a month pain 10/10, 3-5 days “in bed”, R leg radicular symptoms, no spasm or change in curvature §4.71a Rating 20% ~guard/gait 10% 20%-40% (VA NSC) *Under the old spine rules the spine was separated into Lumbar and Thoracic segments and the current Plate V ROM normal values are for combined thoracolumbar ROM. The old spine rules normal values were what the examiner stated. Absent stated values, the references of the day ~2002 varied from forward flexion of 60° to 90° depending on measurement techniques, etc. At the MEB exam, 2 months prior to separation, the CI reported no specific complaints except those comments on the DD Form 2807, that she was on Percocet, morphine (narcotic pain medications) and methacarbamol as need for her back, and “severe lower back down right leg pain limited range of motion.” The examiner also documented that she gave a history that her “right leg will go out due to sciatic nerve damage.” The MEB physical examiner noted that the low back exam was non-tender, with ROM as summarized above, with decreased sensation over the dorsal aspect of the left foot (normal right foot), normal reflexes, normal muscle strength and normal hip flexion. Four months prior to separation the neurologist consultant to the MEB stated the CI had 4-/5 strength in the right hip flexor, right foot dorsi-flexor and right foot external rotators.” The neurologist noted positive right straight leg raising, with deep tendon reflexes reduced to ¼ in the right patellar, trace out of 4 in the right Achilles, with antalgic gait with right hip circumduction to compensate for a subtle foot drop. Furthermore, the neurologist stated the CI was not able to heel walk on the right, but toe walk was normal. Stress gait was not tolerated secondary to pain, and the neurologist recorded “patient with compromised ability to conduct tandem gait secondary to low back pain and foot drop.” The Board acknowledged a chiropractic note within two weeks after the MEB in the record, but found the name on the note did not match the CI’s name and excluded the evidence. At the VA Compensation and Pension (C&P) exam a month after separation, the CI reported that she continued to have daily pain, stated to be 3 on a scale of 0- 10, 10 being the worst pain. Furthermore, the examiner recorded history that the CI stated “at last (least) once a month the pain will go up into the ten-range” and “with this she has (is) having to miss work because she is unable to get out of bed. These episodes can last 3 to 5 days. She states that she is incapacitated with these episodes. She has not been prescribed bed rest, however, by a physician. Lifting is limited to essentially none. She has radicular symptoms going down into the right lower extremity intermittently. With the flare-ups her range of motion decreases by 100%. She is immobile. She uses a cane daily in the mornings. During the day she uses a cane only when she is having a flare up.” The VA examiner noted “gait is normal”, and the above ROM chart entries. The VA examiner stated “all this is done with significant discomfort. Repetitive range of motion testing does not reduce the range of motion, however it does increase the pain.” Motor and sensory exam was normal in the right leg, and reflexes were normal. The Board directed attention to its rating recommendation based on the above evidence. The PEB coded analogously to 5295, lumbosacral strain, and rated 10% for characteristic pain on motion. The VA coded 5243, intervertebral disc syndrome, and deferred rating awaiting the CI to supply new medical evidence. The Board examined the ROMs, noting that the Army and the VA were each using different versions of the VASRD in effect at their respective evaluations. It is obvious that there is a clear disparity between the MEB and VA examinations, with very significant implications regarding the Board's rating recommendation. The Board thus carefully deliberated the probative value assignment to these conflicting evaluations, and carefully reviewed the service file for corroborating evidence from the period preceding separation. Although the CI complained of incapacitation, there was no documentation of physician prescribed bed-rest for coding under 5293 (Intervertebral disc syndrome), nor comparative complaints or entries in the pre-separation record. Without evidence of interval injury the Board could not resolve the decreased ROM in the more proximal VA exam, found more probative value in the MEB exam, and noted the neurologist’s findings. The Board considered other coding possibilities, but could not find a coding that fit the disability better than the choice of the PEB. 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 low back 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. In the matter of the chronic LBP 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 Condition 5299-5295 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120530, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxx, AR20130006863 (PD201200564) 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 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)