RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02506
BRANCH OF SERVICE:  Army	BOARD DATE:  20150402
SEPARATION DATE:  20090426

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Guard E-4 (Infantry) medically separated for a back condition.  The back condition did not improve adequately to meet the physical requirements of his Military Occupational Specialty.  The profile allows 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).  Back pain was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded three other conditions (see rating chart below) for PEB adjudication.  The Informal PEB adjudicated intervertebral disc syndrome, lumbosacral as found unfitting, rated at 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining three conditions were found to be not unfitting.  The CI made no appeals, and was medically separated.

CI CONTENTION:  “Please consider 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 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:

Army IPEB – dated 20090106	VA* - (~41 mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Intervertebral Disc Syndrome	5243	10%	Low Back Strain	5237	NSC	20121011	
Lymphadenopathy	Not Unfitting	No VA Placement	
Deviated Nasal Septum	Not Unfitting	No VA Placement	
Corn of the Right Foot	Not Unfitting	No VA Placement	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20121029 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Back Pain.  This CI has had a long history of back problems.  As a young child, he had a traumatic injury to his back.  He was thrown from his playpen, and he suffered a spinal fracture.  In 2004, prior to service entry, he injured his back during a bar fight.  After entering the Army, he was initially fine.  In 2008, as he was preparing to deploy, his back pain got worse.  It was attributed to wearing individual body armor (IBA).  In March 2008, magnetic resonance imaging (MRI) of the lumbar spine showed a small central disc protrusion at L4-L5, but no significant canal stenosis (narrowing) or nerve impingement.  The neural foramina were patent/open (vertebra not compressing nerve).  The radiologist opined that the small L4-L5 disc protrusion was of “uncertain clinical significance.”  MRI of the thoracic spine showed an abnormality in the mid-thoracic spinal cord, consistent with myelomalacia (softening of the spinal cord) or syringomyelia (please see explanation below).  On 4 April 2008, the CI was seen for follow-up, and based on the MRI results, he was diagnosed with syringomyelia.  [Syringomyelia is a condition where a cyst or cavity (called a “syrinx”) forms in the spinal cord.  It can be caused by trauma or injury to the back.  The back injury can occur many months or years before the post-traumatic syrinx is found.  Symptoms usually begin in young adulthood.  The primary presenting symptom of post-traumatic syringomyelia is back pain.  The back pain is often associated with neurological symptoms in the lower extremities.]

On 21 August 2008, the CI was seen in the neurology clinic, to evaluate a possible seizure episode that had occurred.  The examining physician determined that it was very unlikely that the CI had seizures.  The episode that occurred was much more likely to have been a dream/nightmare, unusual waking direct from rapid eye movement sleep, or a parasomnia.  The Board could not determine why the examining neurologist made no mention of the abnormality in the thoracic spinal cord or the syringomyelia condition which had been diagnosed 4 months earlier.  The CI’s back pain was treated with physical therapy, chiropractic manipulation, and pain medication.  In spite of all treatment efforts, the back pain persisted and MEB was initiated.

During the MEB narrative summary (NARSUM) examination dated September 3, 2008, 7 months prior to separation, the CI walked into the room and sat in a chair without assistance.  He leaned over to remove his shoes without complaint.  He easily climbed onto the examination table.  He obtained the recumbent and the sitting position without discomfort.  Straight leg raise (SLR) was normal.  Neurological exam was grossly intact.  Range-of-motion (ROM) was measured and summarized in the chart below.  Limitation in ROM was due to pain.  There was no additional functional loss due to fatigue, weakness, lack of endurance, or incoordination.  The examiner made note of the syringomyelia abnormality in the spinal cord which was seen on MRI.  However, the examiner’s diagnosis for the back was “Back pain due to use of personal protective gear, such as IBA and ACH.”

Four years later, on 11 October 2012, he had a VA Compensation and Pension (C&P) exam.  He said that his mid-to-low back pain was constant.  The pain was sharp, and was 7/10 in severity.  He did not report “flare-ups” of the back pain.  On physical examination of the back, there was paraspinal tenderness to palpation of the entire thoracolumbar back region (T1 to L5).  No guarding or muscle spasm was noted.  Deep tendon reflexes and muscle strength were normal in both legs.  Sensory testing revealed a decrease to light touch in the left lower leg.  SLRs were negative bilaterally.  No signs or symptoms of radiculopathy were found.  The C&P examiner noted a thoracic spinal cord abnormality, but did not elaborate further.  The examiner opined that the CI’s chronic back pain was caused by the 2004 bar fight which occurred prior to service.

The ROM evaluations which the Board weighed in arriving at its recommendation are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	NARSUM ~7 mos. Pre-Sep
(20080903)	VA C&P ~4 yrs. Post-Sep
(20121011)	
Flexion (90 Normal)	65	60	
Combined (240)	180	190	
Comment	Pain with motion	Pain with motion	
§4.71a Rating	10%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The October 2012 C&P exam was 4 years after separation, and therefore had diminished probative value.  The September 2008 NARSUM exam was much closer to the DOS, and therefore had greater probative value.  At that exam, the examiner wrote in great detail the movements the CI was able to perform.  With ROM testing, there was 65 degrees of flexion, and 180 degrees of combined thoracolumbar ROM.  IAW VASRD §4.71a, a disability rating of 10% is warranted when thoracolumbar forward flexion is greater than 60 degrees, but not greater than 85 degrees.  A rating of 10% is also warranted when combined ROM of the thoracolumbar spine is greater than 120 degrees, but not greater than 235 degrees.

After due deliberation, in consideration of all the evidence, and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends no change in the PEB’s 10% adjudication of the back pain condition.  The Board tried to find a path to a higher rating.  There was not sufficient evidence of muscle spasm or guarding severe enough to cause abnormal gait or abnormal spinal contour.  Additionally, there was no evidence of incapacitating episodes for a higher rating under intervertebral disc syndrome rating formula.  The Board considered other diagnostic codes which could be applied to the CI’s condition, but none resulted in a higher rating.

The Board also considered the matter of radiculopathy.  After review of all the information in the record, there was insufficient evidence of a clinically significant radiculopathy that interfered with performance of military duties.  The CI did have neurological symptoms in his legs.  However, there was no performance-based evidence that the neurological symptoms caused significant interference with satisfactory performance of military duties.  Therefore, the Board concluded that there was no unfitting radiculopathy present at the time of separation.

Other PEB conditions.  Nonpathologic cervical lymphadenopathy, deviated nasal septum, and corn of the right foot were all adjudicated by the PEB as not unfitting.  The Board’s main charge with respect to these three conditions is to assess the appropriateness of the PEB’s fitness determination.  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.  These conditions were reviewed by the action officer and considered by the Board.  The Board noted that these three conditions were not profiled, and none of the conditions were specified as failing retention standards.  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 these conditions.  Therefore, no additional disability ratings are 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 back pain condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  In the matter of the cervical lymphadenopathy, deviated nasal septum, and corn of the right foot, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140526, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXXXX, AR20150014896 (PD2014002506)

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						     XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA