RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201096 SEPARATION DATE: 20030904 BOARD DATE: 20130228 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92G10/Food Service Specialist), medically separated for mechanical lower back pain secondary to congenital vertebral anomaly (spinal bifida) with characteristic pain on motion. He had low back pain (LBP) for 6 to 7 years that progressively worsened. A lumbar magnetic resonance imaging (MRI) showed an anatomical anomaly at the L4 vertebra that was diagnosed as spina bifida occulta. Despite physical therapy the CI did not improve adequately with treatment to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He 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 determined this disability existed prior to service (EPTS) and was not permanently service aggravated but was compensable in accordance with 10 USC Section 1207a. Therefore, the PEB adjudicated the low back condition 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: “During my Medical Board Seperation [sic], my company 1st Sgt kept putting pressure as to when my Medical Board was going to be final. I never appeal my decision due to pressure from my unit to leave, so I could be replaced. Here are some orders from my unit at the time of discharge. My 1st Sgt name was xxxxxxxxxxx.” 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 20030515 VA (2 Mos. Pre -Separation) – All Effective Date 20030905 Condition Code Rating Condition Code Rating Exam Mechanical Low Back Pain 5299-5295 10% Low Back Arthrosis 5292-5295 10% 20030626 .No Additional MEB/PEB Entries. Seasonal Allergic Rhinitis w/ Intermittent Sinusitis, Migraine HA, & Rt Frontal Sinus Cyst 6513-6522 30% 20030626 Lt Knee Patellofemoral Pain Syndrome 5299-5024 10% 20030626 Residual P/O Lt Shoulder 5203 10% 20030626 Supraventricular Arrhythmias 7010 10% 20030618 0% X 3 20030626 Combined: 10% Combined: 50% ANALYSIS SUMMARY: Low Back Condition. The narrative summary (NARSUM) notes that the CI had a long history of non-traumatic LBP and when conservative treatment did not help lumbar spine X-rays and magnetic resonance imaging (MRI) revealed an anomalous L4 vertebra (spina bifida occulta) without evidence of disc herniation or nerve impingement. At the MEB exam, the CI reported that his symptoms of back and leg pain started about 6 years earlier without a specific injury and had been getting progressively worse since then. Activity such as pulling, pushing, repetitive lifting, bending, standing and marching increased his pain. He reported that leaning to the right side could relieve the left sided radiation of his back pain down to his legs. There were some days that he was pain-free, but mostly the pain waxed and waned. On physical exam, range-of-motion (ROM), motor, sensory and reflex exams were normal. At the VA Compensation and Pension (C&P) exam, approximately 2 months prior to separation, the CI reported constant back pain with exacerbations in intensity with activity such as bending, lifting and pulling. There were “no associated features except spasms, numbness, and tingling of bilateral legs.” Posture and gait were noted to be normal. On physical exam, ROM, motor, sensory and reflexes were normal. The Board directs attention to its rating recommendation based on the above evidence. The Board must apply the VASRD rating criteria in effect on the date of the CI’s separation, the 2003 Veterans’ Administration Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine, and the Board did so. The older spine ratings were based on ROM impairment which was subject to the rater’s opinion regarding degree of severity, whereas the current standards specify rating thresholds in degrees of ROM impairment. The older spine ratings also did not have the general spine rating formula provision of including pain (whether or not it radiates). The PEB and the VA both rated the mechanical LBP condition analogous to 5295 at 10%. The evidence in the record is that the CI had LBP with full, but painful ROM, without evidence of radiculopathy or systemic problems, and no incapacitating episodes at the time of separation. The Board was unable to find a pathway to a higher rating under any applicable VASRD code. 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 LBP 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 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 Mechanical Low Back Pain 5299-5295 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120621, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxx, AR20130006167 (PD201201096) 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)