RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD1300084
BRANCH OF SERVICE:  Army	BOARD DATE:  20130507
SEPARATION DATE:  20011229

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (31F/Network Operator/Maintenance) medically separated for a lumbosacral condition.  She experienced an atraumatic onset of back pain in February 2000, significantly aggravated by a subsequent road march.  Comprehensive ancillary investigation failed to yield a precise diagnosis, and the condition did not respond adequately to conservative measures to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated the lumbosacral condition as unfitting, rated 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD) in effect.  The CI made no appeals, and was medically separated with that disability rating.

CI CONTENTION:  “The injury affected was actually a hip displacement due to improper healing... [refers to attached letter from civilian provider] ..., not the back or sacral area as rated upon separation.”  Attached (post-separation) medical records included referenced letter from a civilian chiropractor dated 21 August 2012.  This opines a “primary diagnosis” of “right sided sacroiliitis” and a “secondary diagnosis” of “lumbar subluxation.”

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 rating for the unfitting lumbosacral condition is addressed below.  The requested hip condition was not identified by the PEB, and thus is not within the DoDI 6040.44 defined purview of the Board.  The hip condition, and any other conditions or contention not requested in this application, remain eligible for future consideration by the respective Service Board for Correction of Military Records.

RATING COMPARISON:  
   
Service IPEB – Dated 20011012 | VA (5 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Low Back Pain | 5295 | 10% | Degenerative Disc, L4/5 and L5/S1 | 5293 | 10% | 20020508
No Additional MEB/PEB Entries | Other x 2* | 20020508
Combined:  10% | Combined:  10%
Derived from VA Rating Decision (VARD) dated 20020630 (most proximate to date of separation [DOS]).
* Right ankle and knee conditions, initially not service connected, then rated 0% each (retroeffective) in VARD dated 20030121.

ANALYSIS SUMMARY:  

Lumbosacral Condition.  The earliest entry in the service treatment record (STR) for the condition was a complaint of right low back pain (LBP) in April 2000, which was initially attributed to a urinary tract infection (UTI).  There are frequent subsequent entries for persistence and escalation of the complaint.  A working diagnosis of right sacroiliitis is offered in many of them.  Right sacroiliac (SI) joint injection was performed in November 2000 without lasting relief.  Radiographic studies noted sacralization of L5 (incidental variant), with normal alignment (no subluxation as per 2012 evidence cited above), normal SI and hip joints, and no other abnormalities.  Bone scan was normal.  Magnetic resonance imaging (MRI) (January 2001) noted “mild degenerative disc disease of the lower lumbar spine.”  There were no surgical indications.  Painful trunk motion, but no grossly limited range-of-motion (ROM), and normal neurologic findings are evidenced in various STR entries.  The narrative summary (NARSUM) noted constant pain “between ½ and ¾ of the time when she is awake,” interfering with normal activities and episodically with sleep.  The physical exam from the orthopedic addendum to the NARSUM is excerpted below.
Good lumbar spinal range of motion.  She has some pain with forward flexion and tenderness to palpation over right paraspinous region, SI joint and her right gluteal muscle insertion.  She has nontender hip range of motion bilaterally. She has 5 of 5 motor strength throughout, her DTR's are bilaterally symmetric and she has a mildly positive Faber [for SI joint disease] on the right.
At the VA Compensation and Pension (C&P) evaluation (5 months post-separation), the examiner recorded, “The pain radiates up the back and occasionally down the right leg when the back pain is acute.”  Severity, aggravating factors, or limitations were not elaborated.  The VA physical exam noted a normal gait with no comment on spasm or tenderness.  The ROM evidence is confusing in that the examiner noted “decreased [ROM],” but elaborated 110 degrees of flexion (normal 90 degrees) and “full” but painful motion in all other planes.  Neurological findings were normal.

The Board directs attention to its rating recommendation based on the above evidence.  The 2001 VASRD coding and rating standards for the spine, which must be applied to the Board’s recommendation IAW DoDI 6040.44, differ significantly from the current §4.71a general rating formula for the spine.  The applicable coding options for this case are excerpted below. 
5292 Spine, limitation of motion of, lumbar
Severe ...................................................................................................................................... 40	
Moderate ................................................................................................................................. 20		
Slight ........................................................................................................................................ 10
           5293 Intervertebral disc syndrome:
...
Severe; recurring attacks, with intermittent relief .................................................................. 40
Moderate; recurring attacks .................................................................................................... 20
Mild .......................................................................................................................................... 10
Postoperative, cured ................................................................................................................. 0
5294 Sacro-iliac injury and weakness: [Defaults to 5295 as below.]
5295 Lumbosacral strain:
Severe; with listing of whole' spine to opposite side, positive Goldthwaite's sign, 
marked limitation of forward bending in standing position, loss of lateral motion 
with osteo-arthritic changes, or narrowing or irregularity of joint space, or some
of the above with abnormal mobility on forced motion ...................................................... 40
With muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral,
 	          in standing' position ............................................................................................................. 20
With characteristic pain on motion ......................................................................................... 10
The PEB’s DA Form 199 cited “characteristic pain on motion” for its 10% rating under 5295, and the criteria for the higher ratings were not in evidence.  The 5294 code for sacroiliac disease would have been more clinically precise for this case, but moot to rating (see criteria).  The VA rating decision cited “mild symptoms associated with intervertebral disc syndrome” for its 10% rating under 5293.  Clinically, despite the imaging findings, the CI did not manifest an acute discopathy; so, the VA’s coding choice is not preferable.  There was no evidence of “recurring attacks” which would achieve a rating higher than 10% under 5293, even if applied for the Board’s recommendation.  The only remaining code available is 5292 for limitation of motion.  No rating higher than 10% can be supported under 5292 for the modest, if any, ROM limitation in evidence.  There was no radiculopathy in evidence for achieving additional rating under a peripheral nerve 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 lumbosacral 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 lumbosacral condition and IAW VASRD §4.71a in effect, 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 | 5295 | 10%
COMBINED | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	Physical Disability Board of Review

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20130011457 (PD201300084)

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						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA