RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-02785
BRANCH OF SERVICE:  Army	BOARD DATE:  20150421
SEPARATION DATE:  20060526

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Intelligence Analyst) medically separated for radiating left lower extremity pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  His profile allowed for an alternate aerobic event to satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Lumbar back pain with left leg radiculopathy” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “radiating left lower extremity pain” rated 20%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I feel that as permanent and potentially crippling as my injuries are, a 20 % rating is lower than expected and should be reevaluated at this time.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20060328 | VA - (5 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Radiating Lt Lower Extremity Pain | 5243-8720 | 20% | Sciatica, Lt Lower Extremity assoc w/ Thoracic/Lumbar Spine w/ Paraspinal Muscle Strain; DDD | 5237-8520 | 10% | 20061016
| | | Thoracic/Lumbar Spine w/Paraspinal Muscle Strain; Degenerative Disc Disease | 5237 | 40% | 20061016
Other x 0 (Not In Scope) | Other x 6
Rating:  20% | Combined:  60%
Derived from VA Rating Decision (VARD) dated 20061228 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Lower Back Pain/Left Lower Extremity Pain Condition.  A service medical record note dated 10 January 2005 documented a 5-month history of low back pain (LBP) with numbness in both feet.  The pain was described as shooting and moderate.  A diagnosis of lower back and extremity pain with left piriformis (gluteal muscle compression of the sciatic nerve) syndrome was rendered.  The CI was treated with activity modification and low back class (physical therapy [PT]).  The CI had another acute episode of lower back and left lower extremity radicular pain in June 2005.  X-ray evaluations were normal and the CI was treated with PT for probable discogenic LBP.  A physical therapy note dated 8 July 2005 noted no pain at rest and 1-3/10 at the end of extension.  On 17 August 2005 the CI presented with a 3-day history of increased LBP.  The physical examination demonstrated low back paraspinous tenderness and positive radicular pain testing bilaterally.  A diagnosis of exacerbation of chronic lower back pain was rendered and the CI was treated with intramuscular pain injection and narcotic medications.  A magnetic resonance imaging study dated 8 September 2005 revealed signs of degenerative disc disease (DDD) at the lumbosacral junction with minimal disc protrusion.  On 5 October 2005 the CI presented for care with acute LBP.  The examiner noted that the CI appeared uncomfortable with a slow gait secondary to pain.  The physical examination revealed thoracolumbar flexion limited to 30 degrees of flexion, 5 degrees of extension, and tenderness to palpation at the lumbosacral junction.  A diagnosis of acute on chronic LBP was rendered.  The CI treated with anti-inflammatory medications, narcotic medication as needed and activity modification.  A neurology evaluation dated 2 February 2006 documented a history of radicular symptoms.  The examiner opined that the CI was not a surgical candidate and started neuropathic pain medication.  A nerve conduction study dated 17 February 2006 revealed mild to moderate chronic left lumbar level 4 radiculopathy.  The narrative summary (NARSUM) noted daily lower back pain, rated 7-8/10, and radiating down the left leg approximately 50% of the time.  The physical examination demonstrated a normal gait, unsteady heel to toe walk, hesitant jog, and minimal jump.  Although there was no limitation of motion at this examination, the examiner referenced a focused examination consultation dated 9 January 2006 which documented pain in all directions of motion and positive radicular pain testing on the left.  At the VA Compensation and Pension examination performed 5 months after separation, the CI reported daily back pain which prevented bending and stooping activities.  The pain worsened with standing greater than 30 minutes and flared once week.  The flare ups lasted half a day and were relieved by Tylenol #3 and Naprosyn.  He reported radiation of the pain down the left lower extremity.  The physical examination demonstrated pain in the lower back and bilateral gluteal region in all planes of thoracolumbar motion.  There was additional loss of flexion and extension with repetitive motion.  The gait and lumbar spinal curve were normal.  The neurovascular and muscle strength examinations were normal.  The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)

MEB ~ 3 Mo. Pre-Sep

VA C&P ~ 5 Mo. Post-Sep

Flexion (90 Normal) | 110/115/115 (90) | (30)32
Extension (30) | 25/30/30 (30) | 10
R Lat Flexion (30) | 30/30/30 (30) | (15)16
L Lat Flexion (30) | 25/25/25 (25) | (20)22
R Rotation (30) | 80/75/80 (30) | (30)45
L Rotation (30) | 75/75/80 (30) | (30)45
Combined (240) | 235 | 135
Comment | Flexion was slow and painful. | AO Comments
§4.71a Rating | 10% | 40%
The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the LBP and left lower extremity radiculopathy as a single unfitting coded 5243-8720 (intervertebral disc disease-sciatic nerve neuralgia) and rated 20%.  The VA rated the LBP with left lower extremity condition as DDD and sciatica with disability ratings of 40% and 10% respectively.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  Each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.

Low Back Pain.  The Board noted that the LBP condition was profiled, implicated in the commander’s statement, and forwarded by the MEB as not meeting retention standards.  Board members agreed that the LBP condition was reasonably justified as separately unfitting.  The Board then deliberated rating of the lower back pain condition.  The Board noted that multiple treatment notes and the NARSUM examiner documented pain in all planes of thoracolumbar motion without abnormal gait, abnormal spinal contour, or muscle spasms.  Board members agreed that the evidence met criteria for a 10% rating for LBP condition IAW the general rating formula for diseases and injuries of the spine.  Although the VA examination, 5 months after separation, documented thoracolumbar forward flexion to 32 degrees, Board members agreed that this measurement reflected after separation worsening and that there was no prior to separation evidence of thoracolumbar ROM to support a higher rating.  The Board also considered if the evidence supported a rating higher than 10% under the formula for rating Intervertebral disc syndrome based on incapacitating episodes.  In the 12 months prior to separation the CI presented with three acute episodes of LBP requiring treatment by a physician.  The VA noted the CI reported two incapacitating episodes for one day each in the past 12 months.  Although the duration of the episodes noted in the service treatment record were documented as totaling greater than 4 weeks, there was no evidence of quarters or bed rest prescribed by a physician that met criteria under VASRD code 5243, for incapacitating episodes and a 20% rating.

Sciatic Nerve.  The sciatic nerve condition was implicated in the commander’s statement and forwarded as not meeting retention standards.  The sciatic nerve condition was referenced separate from back pain in multiple treatment notes.  The neurologist diagnosed sciatic neuropathy; which was confirmed by an electromyogram and treated with neurogenic pain medications.  Board members agreed that the sciatic nerve condition was reasonably justified as separately unfitting.  The Board then deliberated rating of sciatic nerve condition.  The sciatic nerve pain described as shooting pain down the posterior left thigh through the calf to the foot with intermittent numbness and subjective weakness most closely approximated the VASRD definition for neuralgia.  The Board noted that a rating equal to moderate incomplete paralysis of the nerve is the highest VASRD rating for neuralgia.  Board members noted that there was no evidence of muscle atrophy, decreased muscle strength, or gait abnormality that rose to the level of moderate incomplete paralysis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the sciatic nerve 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 LBP condition, the Board unanimously determined that it was separately unfitting and recommends a disability rating of 10%, coded 5243 IAW VASRD §4.71a.  In the matter of the left sciatic nerve condition, the Board unanimously determined that it was separately unfitting and recommends a disability rating of 10%, coded 8720 IAW VASRD §4.124a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION | VASRD CODE | RATING
Low Back Pain | 5243 | 10%
Sciatic Nerve Condition | 8720 | 10%
COMBINED RATING | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131220, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXX, AR20150012834 (PD201302785)

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 description without modification of the combined rating or 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						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-02785