RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE: PD-2014-00037		
BRANCH OF SERVICE:  Army	BOARD DATE:  20150701
Separation Date:  20071030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-5 (Human Resources Specialist) medically separated for lumbosacral strain.  The low back condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic low back pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “lumbosacral strain” as unfitting, rated 0%, with likely application of AR 635-40, B-29.  The CI appealed to the PEB President, who upheld the IPEB findings.  Additionally, she elected a Formal PEB, but later withdrew her request.  

CI CONTENTION:  The CI elaborated no specific contention in her application.  

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:  

IPEB – Dated 20070717 | VA* - (8 Days Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Lumbosacral Strain | 5237 | 0% | Lumbar Tendonitis (Claimed as Recurrent Low Back Pain(LBP)) | 5299-5237 | 20% | 20071107
Other x 0 (Not In Scope) | Other x 27
RATING:  0% | RATING:  70%
*Derived from VA Rating Decision (VARD) dated 20080422 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Back Condition.  The CI developed low back pain (LBP) in 2003, without a specific traumatic event.  She underwent extensive physical therapy (PT), chiropractic manipulations, pain management interventions including steroid injections, and medication therapy.  An MRI performed in July 2006 demonstrated herniated discs (HNP) at L3-4 and L4-5 along with degenerative changes with mild spinal canal narrowing.  Neurosurgeon evaluation included a recommendation against surgery.  The MEB Narrative Summary (NARSUM) exam on 7 May 2007, approximately 6 months prior to separation, documented that the CI had LBP 24/7 that extended down her left lower extremity to her toes with numbness and tingling.  She rated her pain at 5-9/10 and noted that her back pain accounted for at least 75% of her pain.  The examiner noted that the CI had several acute flares and required three non-steroidal anti-inflammatory drug (NSAID) injections for the pain, the last being in January 2007.  The CI also required narcotic pain medication three times a week in addition to an oral NSAID and muscle relaxant medication.  Exam documented a normal gait and the CI could walk on heels and toes.  There was no muscle spasm or tenderness and motor, reflex and sensory exams were normal.  Range-of-motion (ROM) testing documented pain-limited forward flexion of 75 degrees (normal 90) and combined ROM of 225 degrees (normal 240) [NOTE:  after applying VASRD 4.71a spine notes for rounding and truncating measurements].  There was no significant change on repetition and an inclinometer was used.  Records indicated that the CI had been placed on quarters for 72 hours for back pain in February, May, and July 2007 (total 9 days).  

The VA Compensation and Pension (C&P) exam approximately 9 days after separation documented that the CI had LBP with radiation to the left lower extremity, which was aggravated by prolonged standing, bending, stooping and lifting heavy weight.  The CI reported that she required medication for neurogenic pain daily, and a strong narcotic and NSAID once weekly to help control the LBP.  Her P3 profile precluded her from running and lifting and she had an epidural steroid injection for her LBP.  The VA examiner stated:  “On examination, (the CI) is walking briskly in the hallway without assistive device with normal gait and posture.”  The CI was able to walk on heels and toes and partially squat.  There was no tenderness.  The examiner stated the CI “would perform only forward flexion to 30 degrees … (combined ROM of 100 degrees) ….  The (CI) stated that she could not perform any further range of motion as it would cause her pain.”  There was no motor weakness, muscle atrophy or radicular neurological deficits present.  A straight leg raise was positive for back pain, but no distal radiation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the back condition as 5237 (lumbosacral strain) and rated at 0%, although the PEB disability description noted pain-limited flexion of 80 degrees (source exam rounded to 75 degrees IAW VASRD rules).  This was likely application of AR 635-40, B-29 (in effect at the time).  The VA coded the back condition analogous to 5237 and rated at 20%.  

There was a large disparity between the Service and VA examinations with implications for the Board's rating recommendation.  The Board deliberated the probative value of these conflicting evaluations, and carefully reviewed the entire file for corroborating evidence from the period preceding separation.  Almost all Service exams documented painful motion or pain-limited motion of the thoracolumbar spine with forward flexion greater than 60 degrees but not greater than 85 degrees; or, combined ROM greater than 120 degrees but not greater than 235 degrees, which meets the 10% VASRD spine rating criteria.  There were some exams which documented, muscle spasm with one exam in the year prior to separation including abnormal gait.  The single exam documenting markedly more limited lower back ROM was the post-separation VA exam.  The VA exam was closest to the date of separation and documented worsened pain-limited ROM than the MEB exam.  The Board adjudged the VA exam as having the highest probative value for rating.  However, the wording in the source VA exam did not indicate pain at the end of active forward flexion to 30 degrees, but a voluntary stopping short of the pain-limit.  The VARD indicated the VA considered their exam as demonstrating forward flexion “greater than 30 degrees but not greater than 60 degrees … ; or combined (ROM) not greater than 120 degrees” for their 20% rating.  The Board agreed with the VA that the VASRD ROM for forward flexion was greater than 30 degrees, but less than 60 degrees, especially when the source VA exam also indicated the lack of any other indication of lower back exam findings (objective evidence for pain limitation [grimacing, etc.]; “posture and gait is excellent;” “walking briskly in the hallway;” no tenderness or spasm; etc.).  

The CI had HNP and the Board considered alternate coding under 5243 (intervertebral disc syndrome).  The Board adjudged that the CI’s episodes of quarters were equivalent to physician prescribed bed rest and met the “incapacitating episodes” (IAW Note 1 for 5243).  The record indicated 9 days of quarters in the last year (within the 10% criteria) which would not provide a rating higher than the 20% under the general spine formula for ROM limitation.  

The Board considered whether additional rating could be recommended under a peripheral nerve code, for the associated lower leg radicular symptoms at separation.  Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating to disability in spine cases.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  There was no fixed sensory deficit, the subjective paresthesias (numbness and tingling) in this case had no functional implications, and there was no motor weakness in evidence.  There was thus no evidence of a separately ratable functional impairment (with fitness implications) from any residual radiculopathy; and, the Board cannot support a recommendation for an additional disability rating based on peripheral nerve impairment.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.7 (higher of two evaluations), the Board recommends a disability rating of 20% for the low back 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.  As discussed above, PEB reliance on AR 635-40 for rating the back condition was operant in this case and the condition was adjudicated independently of that instruction by this Board.  In the matter of the lumbosacral strain condition, the Board unanimously recommends a disability rating of 20% coded 5237 IAW VASRD §4.71a, without the addition of any unfitting or ratable peripheral nerve condition.  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; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

UNFITTING CONDITION | VASRD CODE | RATING
Lumbosacral Strain | 5237 | 20%
COMBINED | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131216, 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, AR20150013243 (PD201400037)

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		     XXXXXXXXXXXXXXX
		     Deputy Assistant Secretary of the Army
		         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2014-00037