RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201245 SEPARATION DATE: 20061021 BOARD DATE: 20130307 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve SSG/E-6 (41L/Administrative Sergeant), medically separated for chronic low back pain (LBP) which could not be adequately rehabilitated for the CI to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent U2/L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded seven additional conditions, as identified in the rating chart below, for Informal Physical Evaluation Board (IPEB) adjudication. The IPEB adjudicated the LBP as a prior to service condition exacerbated, but not permanently aggravated, by service and therefore not ratable. The CI appealed to the Formal PEB (FPEB) which did determine permanent aggravation and adjudicated the chronic LBP condition as unfitting and rated it 0% with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting. CI CONTENTION: “Prior to mobilization, I was a Reservist stationed at the 63rd Regional Command Center, in Los Alamitos, CA, and transferred into the 394th AG Company. I was a Secretary for the Los Angeles City Planning Department performing administrative duties and restrictions for lifting no more than 30 pounds. As a Reservist, I had a profile for right shoulder impingement syndrome and carefully monitored my limitations for this injury. During mobilization, I began rigorous training and my lower back and right shoulder pain/problems recurred. I was deployed to Camp Anaconda, Iraq, February 13, 2005, as a Postal Supervisor. The duties required lifting over 30 pounds, prolonged standing, pulling, reaching overhead, stooping, constant bending and turning. Performing these physically demanding and repetitive activities caused aggravation and made the pre-existing back and shoulder injuries impossible to continue to wear protective gear and perform the duties expected of my position as NCOIC of Postal Operations. During my deployment, I was placed on several profiles which prevented the wearing of body armor. I was released from active duty early because of this and transferred to Medical Hold at Ft. Lewis, WA. A VA Orthopedic Dr. recommended that I have surgery (Attach 1). I had arthroscopy with subacromial decompression and excision of the distal clavicle surgery on the right shoulder July 2008 (Attach 2). It was believed that I was a Postal Worker since I injured my back picking up a heavy mail bag. However, during my Board Hearing, I explained that I had been a Secretary for 30 years with the City, and not a Postal Worker. After the Board discovered what my actual career was, the decision was changed to recognize the lower back injury as exacerbation from the deployment. Since the lower back injury was the only injury listed as unfitting, the Board only dealt with that one issue. Therefore, I respectfully request this Board to reconsider the items listed below as "service- connected" or "permanently aggravated by military service. I am respectfully requesting review of the following: 0% rating for low back and disabilities that were not found unfitting: Low back pain secondary to multilevel lumbar degenerative joint and degenerative disk disease - prevented wear of body armor/protective gear, etc. Right Shoulder bursitis - chronic pain, weakness and instability prevented wear of body armor/protective gear, etc. Degenerative disk disease of the cervical spine - prevented the proper wearing of kevlar, military gear, etc. Bilateral knee osteoarthritis - chronic pain and impaired walking, marching, running, jumping, etc. Plantar Fasciitis - prevented the proper wearing of military footwear and impaired walking, marching, running, jumping, standing, etc. Pes Planus - prevented the proper wearing of military footwear and impaired walking, marching, running, jumping, standing, etc. All of these issues prevented me from satisfactorily performing my duties as a Soldier” 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 the unfitting condition, LBP, will be reviewed. The additional conditions deemed not unfitting by the PEB and requested for consideration by the CI (right foot pain secondary to pes planus, plantar fasciitis, fractured fourth phalanx; right shoulder bursitis; bilateral knee osteoarthritis; degenerative disk disease of the cervical spine) also meet the criteria prescribed in DoDI 6040.44 for Board purview and are addressed below. 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 FPEB – Dated 20060822 VA (12 Mos. Post-Separation) – All Effective Date 20061022 Condition Code Rating Condition Code Rating Exam Chronic Low Back Pain 5237 0% DDD and Facet Joint Arthritis L5- S1 5243 NSC 20071022 Right Foot Pain Secondary to Pes Planus, Plantar Fasciitis and Fractured 4th Phalanx Not Unfitting Left/Right Plantar Fasciitis (claimed as Bilateral Feet Pain) 5099-5020 0% 20071022 Menopausal Symptoms Not Unfitting NO VA ENTRY Right Shoulder Bursitis Not Unfitting Right Shoulder Condition 5201 NSC 20071022 Bilateral Knee Osteoarthritis Not Unfitting Early Osteoarthritis of the Bilateral Knees 5010 10% 20071022 Hypothyroidism Not Unfitting Hypothyroidism 7903 10% 20071022 Hyperlipidemia Not Unfitting Hyperlipidemia 7099-7005 NSC 20071022 DDD of the Cervical Spine Not Unfitting Minimal …w/ Cervical DDD 5237 10% 20071022 .No Additional MEB/PEB Entries. Varicose Veins, Left Leg 7120 10% 20071022 Varicose Veins, Right Leg 7120 10% 20071022 0% X 5 / Not Service-Connected x 11 20071022 Combined: 0% Combined: 40%* *Rating increased to 50% effective 20061022 with addition of Left Shoulder Impingement condition at 10% (see 20090625 VARD pg 220 of CPF) ANALYSIS SUMMARY: Chronic Low Back Pain Condition. There was one goniometric range-of-motion (ROM) evaluation in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. Thoracolumbar ROM MEB ~ 6 months Pre-Sep VA C&P ~12 Mos. Post-Sep Flexion (90 Normal) forward flexion at hip by reaching to her knees 40 Combined (240) 180 Comment mild TTP paraspinal lumbar muscles; nml gait ROM not affected by pain. Posture and gait WNL. §4.71a Rating 10% 20% According to the MEB narrative summary (NARSUM), dated 17 May 2006, the CI injured her back in 1998 while working as a civilian for the city of Los Angeles. A VA Compensation and Pension examination (C&P), performed on 15 October 2007, documented that she had a Workman’s Compensation claim against the city of Los Angeles pending at the time of activation. The claim was for shoulder and back injuries secondary to a fall on the job. She also stated that she had a P3 profile at the time of activation which was on 4 November 2004. She was seen for several times for shoulder and back pain prior to deployment in February 2005. She continued to have LBP which was aggravated by the wear of combat gear. While back in the United States, she had a civilian magnetic resonance imaging (MRI) exam which showed minimal disc bulging at L4-5 and L5-S1 with degenerative disc disease (DDD) at L3-4; the action officer noted that this is not unusual for someone her age. She was evaluated by neurosurgery on 9 August 2005 and noted to have an essentially normal examination and to not be a surgical candidate. She returned to the theater of operations where her pain continued. On or about 6 December 2005, she was returned 2 months early to her home station for consideration of an MEB. On 19 December 2005, she underwent another MRI for LBP and right greater than left hip pain; this MRI noted the additional findings of degenerative joint disease (DJD) L3-S1 and mild disc protrusion with foraminal narrowing at L5-S1 compared to the prior study. She was referred for an orthopedic examination, but the record of this appointment is not in evidence. On 07 March 2006, the CI underwent an evaluation and testing by a neurologist. Electrodiagnostic testing was normal without evidence of neurological compromise. At the MEB orthopedic evaluation on 12 April 2006 (6 months prior to separation), the CI reported that she had an 8 year history of LBP which she developed after lifting heavy boxes as an office worker and had managed conservatively with significant pain relief. Her LBP was aggravated while deployed due to the wear of body armor and lifting heavy objects. On examination, she was noted to be obese. Her strength, reflexes, and sensation were normal as were her gait, heel-walk, and toe-walk. Bilateral straight leg raise (SLR), a provocative test for nerve root irritation, was negative. She had mild tenderness to palpation in the lower back muscles, but there was no comment regarding spasm. She could perform forward flexion at the hip by reaching approximately to her knees and she could extend to approximately 10-15 degrees. No comment was made on whether the limitation was secondary to pain or mechanical limitations, such as body habitus; however, this is consistent with flexion which ranges from a slight reduction to normal. At the general MEB NARSUM on 17 May 2006 (5 months prior to separation), the CI provided no new history from above. The examination showed that she was 68 inches and 196 pounds. The lumbar spine showed no tenderness to palpation and full active ROM. The CI had no radiculopathy with normal reflexes, sensation, and strength. Bilateral SLRs were negative. There was no comment regarding gait or back spasm. No signs of non-organic pain were present. She was noted to be able to perform all of her duties as an administrative specialist in garrison. No incapacitation was documented. The C&P examination on 22 October 2007 (12 months post-separation), the CI reported that she was unable to garden, vacuum or push a lawn mower secondary to her knee and back pain. On examination, she was 68 inches tall and 232 pounds. Posture and gait were normal and she used no assistive devices. The neurological examination was normal. The ROM was notable for flexion limited to 40 degrees, but without DeLuca criteria present. Again, no comment was made regarding the cause of the limitation. The Board noted a 36 pound weight gain since the NARSUM examination. There was no mention of spasm. Repeat X-rays of the lumbar spine on 22 October 2007 noted no notable progression of the lower back disc disease. The VA examination was just outside of the 12 month window utilized by the Board. In addition, the examiner did not specifically evaluate the back and the ROM values were obtained as an addendum. Both of these factors reduce the probative value of the examination. Under the discussion for the cervical spine it was documented that there were no signs of intervertebral syndrome. The CI did undergo a second C&P examination on 25 February 2008, 16 months after separation, which was not specific for the back. However, it noted that she ambulated without the use of an assistive device and that she could sit up from a supine position and transfer from a chair to the examination table without major difficulty. Her gait was normal and she could stand on both her toes and heels, taking a few steps. There was no evidence of limitation in standing or walking. The action The Board directs attention to its rating recommendation based on the above evidence. It determined that the NARSUM general examination, which documented a normal ROM and neurological examination, was most consistent with the predominance of other evidence. It also noted that the CI had a Workman’s Compensation claim for back pain pending at the time of activation and that the VA determined the condition to not be service-connected as it existed prior to service (EPTS). However, the PEB determined that there had been permanent service aggravation and rated the condition at 0%. The Board considered the findings. There was no history of incapacitation in the service treatment record. The NARSUM documented a normal neurological examination and ROM. Neither painful motion nor spasm was documented. There were minimal degenerative changes on X-rays and the MRIs showed DDD typical for the age of the CI. The Board considered the various coding options available for the back condition. None provided a route to a rating higher than the 0% adjudicated by 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. Contended PEB Conditions. The conditions adjudicated as not unfitting by the PEB and that were also contended by the CI are right foot pain secondary to pes planus, plantar fasciitis, and fractured 4th phalanx, right shoulder bursitis, bilateral knee osteoarthritis, and DDD of the cervical spine. The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The Board must demonstrate that by a preponderance of the evidence, the above contended conditions were each separately unfitting. Right Foot pain Secondary to Pes Planus, Plantar Fasciitis, and a Fractured 4th Phalanx. An MEB podiatry consult for plantar fasciitis on 1 March 2006 notes that the CI had intermittent right heel pain for over a year and also had painful right 5th hammertoe. The examiner also noted the CI had trauma to right 4th toe on 10 February 2006. The examiner additionally wrote that "Pt notes it is her back, not her feet, which keep her from performing duties." An X-ray at the time revealed a minimally displaced fracture of the toe and pes planus. She was treated with taping of the affected toe. The examiner noted that the prognosis is good and that the CI met retention standards. Serial X-rays of the toe showed healing and the expected prognosis was normal. The CI was given a temporary profile that cited her right chronic foot pain and 4th toe fracture that expired 30 days later without renewal. The MEB examiner determined that the CI met retention standards as did the MEB. The commander specifically stated that although the CI's chronic foot pain and 4th toe fracture of the right foot precluded the CI from performing work in a field or tactical environment, she was able to perform her duties (in garrison) within the limits of her profile. After due deliberation in consideration of the preponderance of the above cited evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB determination of the right foot pain secondary to pes planus, plantar fasciitis, and fractured 4th phalanx as being not unfitting. Right Shoulder Bursitis: The CI had an 8 year history of right shoulder problems and had a Workman’s compensation claim pending at activation. A right shoulder MRI on 19 December 2005 showed tendinopathy and mild bursitis of the right shoulder. The CI was treated non- surgically with PT. A MEB orthopedic consult on 1 March 2006 (7 months prior to separation) noted the CI had pain with movement at the shoulder and decreased abduction. The examiner noted that the right shoulder bursitis is anticipated to continue to improve and concluded that the CI met retention standards. The MEB NARSUM also concluded that the right shoulder bursitis condition met retention standards. The CI was given temporary profiles for the shoulder and on 8 June 2006 (4 months prior to separation), she was given a permanent U2 profile related to the right shoulder. The commander’s letter made no specific mention of the shoulder condition. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that while the CI was receiving ongoing treatment for her right shoulder condition, this condition was not separately unfitting at the time of separation. Bilateral Knee Osteoarthritis: The CI fell and hurt her right knee in March 2005 and was treated conservatively. X-rays on 1 March 2006 were normal. An MRI on 9 Apr 2006 revealed some thinning of the lateral collateral ligament. At the MEB orthopedic consult, the CI stated that the pain did not occur daily and increased with activity. On examination, she had minimal swelling of the right knee, but diffuse tenderness was present. Her knee was stable with full ROM. The examiner concluded her prognosis is good and that she met retention standards. There is limited information regarding the left knee. An MRI of the left knee on 8 May 2006 (2 months prior to separation) was normal. The MEB orthopedic consult made no mention of a left knee problem. The MEB NARSUM noted no abnormalities the knees on examination and concluded that the bilateral knee osteoarthritis condition met retention standards. There was only one temporary profile, dated 16 May 2006, that mentioned a diagnosis of "knee pain" without specifying the right or left knee. A subsequent permanent profile signed 8 June 2006 did not mention any knee pain as basis for limitations. The commander’s letter made no mention of a knee problem. After due deliberation, in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB determination of the bilateral knee osteoarthritis condition as being not unfitting. DDD of the Cervical Spine: The CI had an MRI of the cervical spine on 7 June 2006 on referral from urology during an evaluation for loss of bladder control. The MRI showed disk herniations and degenerative changes at several levels in the cervical spine. The CI was evaluated by physical therapy and had no functional impairment related to this condition. She had normal ROM and was without radicular symptoms; she did have subjective complaints of pain. She was treated conservatively with cervical traction. There was no cervical tenderness or spasm. The MEB concluded that the DDD of the cervical spine met retention standards. The CI was never profiled for the cervical spine condition. The commander’s letter made no mention of the cervical spine. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB determination of the cervical spine condition as being not unfitting. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and, therefore, no additional disability ratings can be recommended. 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 low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended right foot pain secondary to pes planus, plantar fasciitis, and fractured 4th phalanx; right shoulder bursitis; bilateral knee osteoarthritis; and, DDD of the cervical spine conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. 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 5237 0% COMBINED 0% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120822, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130006147 (PD201201245) 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 xxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)