RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02419
BRANCH OF SERVICE:  Army	BOARD DATE:  20150224
Separation Date:  20040621

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Automated Tactical Data System Specialist) medically separated for lumbar spine with lower left leg numbness.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “left lower extremity numbness” and “low back pain (LBP)” conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (farsightedness and poor heat tolerance) as medically acceptable for PEB adjudication.  The Informal PEB adjudicated “low back pain…numbness in left leg” as unfitting, rated 0% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.

CI CONTENTION:  “All Conditions”

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 20040430 | VA* - (~2 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
LBP…Numbness in Left Leg | 5237 | 0% | Lumbosacral Strain | 5237 | 10% | 20040826
Poor Heat Tolerance | Not Unfitting | Residual Heat Stroke | 7999-7900 | NSC | 20040826
Farsightedness | Not Unfitting | No VA Placement
Other x 0 (Not In Scope) | Other x 2
RATING:  0% | RATING:  10%
*Derived from VA Rating Decision (VARD) dated 20050110 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

LBP…Numbness in Left Leg Condition.  The CI developed back pain while carrying a rucksack during Basic Training in June 2002.  He was followed by physical therapy (PT) for evaluation and treatment.  The CI presented to the emergency room (ER) for left leg numbness.  The podiatrist documented that the CI reported left foot numbness for 2 weeks after he tripped on a rock and fell with pain in the lower back.  There were physical exam findings of mild pain left ankle and loss of sensation on the left foot with normal strength.  The examiner referred the CI to neurology and opined that the left foot numbness was most likely due to his lower back.  The podiatrist noted an improvement in the left foot paresthesias and neuropathy.  The neurologist documented mid-lumbar spine tenderness back pain with forward flexion.  Sensory exam showed decreased pin prick in left knee, leg and foot; total loss of position sense in left big toes and total loss of vibration in left foot to knee.  An electromyogram performed on 11 September 2003 demonstrated a normal exam.  There was no evidence of left L3-S1 radiculopathy/plexopathy or generalized sensory motor polyneuropathy.  The examiner started the CI on medication (Neurontin) for neuropathic pain.  A lumbar spine magnetic resonance imaging demonstrated a mild diffuse L4-5 disc bulge without clear evidence of nerve root impingement.  The neurologist documented that there were no significant objective findings to indicate radiculopathy, nor was there any focal weakness or asymmetrical reflexes.  The examiner further opined that most, if not all, of the findings were psychological.  The CI was referred back to PT and followed throughout in 2004.  The PT exam approximately 4 months prior to separation completed range-of-motion (ROM) evaluations for the MEB examiner.  The PT physical exam findings are summarized in the chart below.  The MEB narrative summary (NARSUM) exam, approximately 4 months prior to separation, documented difficulty with walking and running. It also noted a profile that prevented him from running, taking the PT test or wearing a backpack.  The CI was allowed to walk at his own pace.  The neurologist noted that the CI was able to walk on his heels and do a tandem gait with eyes open and closed without difficulty.  However, the sensory exam showed sensation was totally lost in the left lower extremity up to the mid-thigh, which did not follow any real physiological distribution.  

The VA Compensation and Pension (C&P) exam approximately 2 months after separation documented that the CI reported a sense of numbness to the left upper thigh and gluteal area and residual pain only in the low back and left sacral area, which was exacerbated by bending and lifting.  The CI also reported that he had no perception of his left foot in terms of position or location, or in terms of what he might be walking on.  

As mentioned above, there were multiple ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation as summarized in the chart below.

Thoracolumbar ROM (Degrees) | PT/NARSUM 4 Mos. Pre-Sep | PT ~2 Mos. Pre Sep | VA ~2 Mos. Post-Sep
Flexion (90 Normal) | 30 | 80 | NO ROMs
Combined (240) | 150 | 230 | -
Comment | Inclinometer used & lumbar (not thoracolumbar) ROM; Pos. tenderness to palpation; Normal strength & reflexes; Decreased sensory function left leg | Goniometer used for thoracolumbar ROM testing; No painful motion; No Waddell’s signs | Normal gait; Pos. tenderness without muscle spasm; Neg. SLR; Normal strength & reflexes; Decreased sensory function left leg
§4.71a Rating | N/A (PEB 0%) | 10% | 10% (VA 10%)

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the LBP…numbness in left leg condition as 5237 (lumbosacral or cervical strain) rated at 0%.  The VA coded the lumbosacral strain condition as 5237 rated at 10% citing “Based on the DeLuca criteria, we are granting you an additional 10 percent for your limited range of motion due to pain.”  The Board could not find any C&P exam ROM measurements for the thoracolumbar spine in the evidence present for review.  The General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease.”  The ROM measurements referred to in the NARSUM were obtained by a PT who used an inclinometer to obtain “lumbar” spine measurements, thus not meeting VASRD §4.46, for accurate measurement.  The Board agreed that the comprehensive PT exam performed approximately 2 months prior to separation was closer to separation and contained the required data for basing its rating recommendation and thus was assigned exclusive probative value.  The CI met the 10% rating criteria for “forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees” and “combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.”  Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  The sensory component in this case has no functional implications.  There was no motor impairment that could be linked to any physical impairment.  Since no evidence of functional impairment exists in this case, the Board cannot support a recommendation for additional rating based on peripheral nerve impairment.  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 LBP…numbness in left leg condition without the additional coding of a neuropathy condition.

Contended PEB Conditions.  The contended conditions adjudicated as not unfitting by the PEB were farsightedness and poor heat intolerance.  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  None of these conditions were profiled; the CI was only profiled for the LBP with left leg numbness and weakness.  None of the contended conditions were implicated in the commander’s statement; and, none were judged to fail retention standards.  All were reviewed and considered by the Board.  There was no indication from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the farsightedness and poor heat intolerance conditions and therefore, no additional disability ratings can be recommended.

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 low back pain …numbness in left leg condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended farsightedness and poor heat intolerance conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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:

UNFITTING CONDITION | VASRD CODE | RATING
Low Back Pain …Numbness in Left Leg | 5237 | 10%
RATING | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140516, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX     
President 
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, AR20150010602 (PD201402419)

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 10% 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-2014-02419