RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXX CASE: PD1201842 BRANCH OF SERVICE: ARMY BOARD DATE: 20130313 SEPARATION DATE: 20060228 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (31B/Military Police) medically separated for lumbar disc disease with chronic radiating pain. He experienced an onset of low back pain (LBP) in 2003 while on patrol in Iraq. Extensive physical therapy and epidural steroid injections (ESI) did not improve the pain. He could not be adequately rehabilitated 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 also identified and forwarded thoracic back pain as unfitting which was consolidated with the Physical Evaluation Board (PEB) LBP condition. Additionally, intermittent erectile dysfunction was forwarded to the PEB as a “not unfitting” condition. The Informal PEB (IPEB) adjudicated the LBP as unfitting, rated 20%, with likely application of the Veterans’ Administration Schedule for Rating Disabilities (VASRD). The CI appealed to a Formal PEB (FPEB) which conferred a 10% rating, citing VASRD criteria; and he was medically separated with 10% disability. CI CONTENTION: “The med board said that “the only thing in my med records was that I take pain medication.” SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The unfitting LBP condition (lumbar spinal stenosis) meets the criteria prescribed in DoDI 6040.44, and is accordingly addressed below. No other conditions are 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. Also IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus 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 ratable severity at the time of separation. RATING COMPARISON: Service FPEB – Dated 20060206 VA - (3 Mos. Post Separation) Condition Code Rating Condition Code Rating Exam Low Back Pain 5237 10% Lumbar Strain 5237 10% 20060525 Erectile Dysfunction Not Unfitting Erectile Dysfunction 7522 0% 20060525 No Additional MEB/PEB Entries Other x 2 20060525 Combined: 10% Combined: 10% VARD 20060808 most proximate to Date of Separation ANALYSIS SUMMARY: Low Back Pain (LBP). While deployed to Iraq, the CI experienced a very rough ride in a Humvee. Since then, he has had problems with LBP. Several different treatment options were tried, including epidural injections and physical therapy (PT). However, in spite of treatment his LBP persisted, and an MEB was initiated. His MEB clinical evaluation was on 17 October 2005. In addition to the LBP, the CI also reported intermittent pain in the right leg, which often stops at mid-thigh but occasionally goes into the right foot. He denied bowel or bladder incontinence. Physical exam of back showed bilateral lumbar muscle spasm and tenderness over the lumbar muscles. Straight leg raise (SLR) on both sides caused pain in lower back. There was normal heel and toe walk, normal reflexes, and normal sensation. As noted above, he was medically separated from the Army in February 2006. Three months later, he had a VA Compensation and Pension (C&P) exam. He reported constant, aching LBP. Posture and gait were normal. Examination of thoracolumbar spine showed no muscle spasm, no radiating pain on movement, and negative SLR bilaterally. There was symmetry of spinal motion, and normal spinal curvature. Neurological exam of lower extremities was normal. X-rays of thoracic and lumbar spine were within normal limits. The three goniometric range-of-motion (ROM) evaluations which the Board weighed in arriving at its rating recommendation are summarized in the chart below. Thoracolumbar ROM PT – 5 mos. Pre-Sep (20050927) MEB – 2 mos. Pre-Sep (20060105) VA – 3 mos. Post-Sep (20060525) Flexion (90° is normal) 65° 60° 90° Combined (240° is normal) 205° 195° 240° Comment Pain with motion Pain with motion Pain with motion §4.71a Rating 10% 20% 10%* *10% in May 2006 based on VASRD §4.40 (Functional loss), §4.45 (The joints), and §4.59 (Painful motion) The Board carefully reviewed all evidentiary information available and directs attention to its rating recommendation based on the above evidence. The Army PEB and the VA both chose VASRD code 5237 (lumbosacral strain) and assigned a 10% rating. At the January 2006 MEB exam, the CI was only able to flex his back to 60 degrees. This exam was much closer to the date of separation than either of the other two goniometric evaluations. IAW VASRD §4.71a, a 20% rating is appropriate when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees. The Board also considered the matter of radiculopathy. On examination, motor strength testing had shown no objective evidence of muscle weakness. The CI’s radiculopathy was subjective and sensory only. After reviewing all of the information regarding the radicular findings, there was insufficient evidence of a clinically significant neuropathy that interfered with satisfactory performance of military duties. Therefore, his radiculopathy was not unfitting at the time of separation from service. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends a rating of 20% for the LBP condition. It is appropriately coded 5242 (Degenerative arthritis of the spine), and IAW VASRD §4.71a, meets criteria for the 20% rating level based on his forward flexion not greater than 60 degrees. 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 LBP condition, the Board unanimously recommends a disability separation rating of 20%, coded 5242, IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Chronic, radiating low back pain 5242 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20121008, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxx, 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 xxxxxxxxxxxxxxxxxxxxx, AR20130006286 (PD201201942) 1. 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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards) CF: ( ) DoD PDBR ( ) DVA