RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201318 SEPARATION DATE: 20011006 BOARD DATE: 20130305 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92Y/Supply Specialist), medically separated for chronic low back pain (LBP). Low back symptoms followed a motor vehicle crash in January 2000, and following conservative treatment, did not improve adequately to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She 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 adjudicated the chronic LBP condition as unfitting, rated 10%, with application of the Department of Defense Instruction (DoDI) 1332.39 and the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: “Disc problems, migraines and other health issues preventing me to fulfill the requirements of a 92Y.” 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 chronic back pain condition requested for consideration meets the criteria prescribed in DoDI 6040.44 for Board purview, and is accordingly addressed below. The other requested conditions [migraines and other health issues] are not within the Board’s purview. Any condition 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 20010814 VA (~3 Mos. Post-Separation) – All Effective Date 20011007 Condition Code Rating Condition Code Rating Exam Chronic LBP 5299-5295 10% Low Back Condition 5293 20%* 20020130 No Additional MEB/PEB Entries Residual, Migraine Headaches 8100 30% 20020130 Residuals, Left Knee Disability 5010-5261 10% 20020130 0% X 1 / Not Service-Connected x 4 20020130 Combined: 10% Combined: 50% *Reduced to 10% effective 20050401, VARD 20050111; missed C&P exam 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 Department of Veterans Affairs (DVA) but not determined to be unfitting by the PEB. However the 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 disability rating should the 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 Condition. Symptoms of LBP first began secondary to a bus rollover accident when the CI was enroute from Advanced Individual Training (AIT) to her first duty station on 22 January 2000. She was evaluated at a civilian emergency department and released. She was seen the next day and diagnosed with multiple sprains and strains. Symptoms of lumbar pain persisted, and magnetic resonance imaging (MRI) performed 23 February 2000 was normal without evidence of disc herniation or disc protrusion. Service medical records document continued care by orthopedics, but symptoms failed to resolve with treatment. At an orthopedic evaluation on 24 January 2001, flexion was documented as reaching finger tips to within four inches of the floor, extension 30 degrees, and side bending of 20 degrees to both sides. Strength, sensation and reflexes were normal. The orthopedic surgeon diagnosed mechanical LBP. At the time of the MEB narrative summary (NARSUM) on 23 July 2001, the CI reported persistent LBP. The CI reported that she was not taking any medications for the pain, since no medication had helped. The MEB physical exam noted that the spine was “within normal limits,” with “mild tenderness at the left paraspinal lumbar musculature.” The neurological examination was with normal limits. The VA Compensation and Pension (C&P) examination performed 30 January 2002, 4 months after separation, noted that the CI continues to complain of LBP, which she states “happens every day.” She reported “pain down the back of her right thigh into her knee, however, she does not have pain extending down her feet or any numbness or paresthesias in her feet.” She denied any bowel or bladder incontinence. On examination, lumbosacral spine range-of-motion (ROM) was 60 degrees, extension 20 degrees, rotation 90 degrees. Strength and reflexes were normal and straight leg raise (SLR) test was negative. The examiner noted that the CI “probably has mechanical low back pain without any evidence of radiculopathy.” A CT scan, 28 February 2002, 5 months after separation, demonstrated bulging discs at L3-4 and L4-5 without impingement upon nerve structures. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated 10% for characteristic pain on motion using the code for lumbosacral strain 5295. The VA rated the condition 20% for recurring attacks of moderate intervertebral disc syndrome (5293). 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 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. The Board must correlate the above clinical data with the 2002 rating schedule, in which the applicable diagnostic codes include 5292 (limitation of lumbar spine motion), 5293 (intervertebral disc syndrome), and 5295 (lumbosacral strain). The Board first considered the rating under the VASRD diagnostic code 5292 in effect at the time. The MEB NARSUM did not document a ROM examination; however, the orthopedic examination in January 2001 documented slight limitation of motion with the ability to reach the finger tips to within 4 inches of the floor. The Board noted the post separation C&P examination reported “lumbosacral spine” ROM, and further noted that this examination occurred prior to the current VASRD guidelines that utilize combined thoracolumbar ROM. The Board therefore concluded the C&P examiner was reporting lumbosacral ROM without the inclusion of thoracic motion. Normal lumbar flexion is 60 degrees. The reported 60 degrees of lumbosacral flexion is normal and would be consistent with the ability to reach the fingertips to within four inches to the floor, as documented by the prior orthopedic examination, and is consistent with the normal MRI. The Board concluded the preponderance of evidence supported no higher than a 10% rating under 5292, limitation of lumbar spine motion. The Board next considered whether a higher rating was warranted under the guidelines for intervertebral disc syndrome, code 5293, which was used by the VA in January, 2002. MRI in February 2000 demonstrated no evidence of intervertebral disc disease. Although the CI did report radiating pain, all examinations were negative for signs of radiculopathy or objective neurologic findings. The Board noted the CT scan following separation demonstrating bulging discs without impingement on neural structures. The Board concluded that the CI’s back pain was more consistent with the mechanical LBP diagnosed by orthopedic surgery. Regardless, the Board also concluded the back pain condition did not approach the 20% rating under the 5293 code. The Board then considered the rating under the code, 5295, lumbosacral strain, utilized by the PEB, and noting that the diagnosis of lumbosacral strain had been documented on 9 January 2001. The Board discussed if the evidence would support a higher rating under this code. There was no documentation of muscle spasm on extreme forward bending, and no loss of lateral spine motion to support the 20% rating. The Board concluded that the preponderance of evidence did not support a rating higher than the 10% rating assigned by the PEB. After due deliberation, considering all 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 (code 5299-5295). 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. As discussed above, PEB reliance on DoDI 1332.39 and the USAPDA pain policy for rating chronic LBP was operant in this case and the condition was adjudicated independently of that instruction by the Board. 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 5299-5295 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120626, 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 / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxx, AR20130007524 (PD201201318) 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 xxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)