RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: Army

CASE NUMBER: PD1100118 SEPARATION DATE: 20020521

BOARD DATE: 20120222

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (74B, Information Systems) medically separated for chronic back pain. He was treated, but did not respond adequately to fully perform his military duties or meet physical fitness standards. He underwent a Medical Evaluation Board (MEB). The back pain condition was forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. Retropatellar pain syndrome (RPPS) was listed on the DA Form 3947 as medically acceptable. The PEB found the back pain condition unfitting, and rated it 10% IAW the Veterans Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was thus separated with 10% disability.

CI’s CONTENTION: The CI made no contention in Block 3 of DD Form 294.

RATING COMPARISON:

ANALYSIS SUMMARY:

Chronic Back Pain. The CI has had a long history of gradual onset, mid and low back pain. He has been treated with oral medication, back brace, physical therapy, and chiropractic care. In October 2001, x-rays showed mild lumbar scoliosis, vertebral endplate sclerosis at L4, and some minimal degenerative disc disease at T4-T5. He was diagnosed with mechanical mid & low back pain. It was decided that surgery was not indicated. Due to persistent pain, the CI was issued a permanent profile and an MEB was initiated. At his February 2002 MEB exam, three months prior to separation, the CI reported constant back pain that was worse with bending, lifting, twisting, sit-ups, or push-ups. He denied problems with walking or running, as long as the surface was level. On exam, he had some tenderness to palpation on both sides of his lower thoracic spine, but no palpable muscle spasm. Straight leg raise was negative bilaterally. Neurological exam was normal and there were no Waddell signs. Range of motion (ROM) is shown in the chart below.

At his April 2002 VA Compensation and Pension (C&P) exam, one month prior to separation, the CI complained of back pain, but denied radiation to the lower extremities. Posture and gait were normal. No scoliosis of the spine was noted. Two relevant goniometric ROM evaluations were in the record, and these two exams are summarized below.

The VASRD coding and rating standards for the spine, which were in effect at the time of separation, were modified in September 2002, and then were changed again in September 2003. The older standards were subject to the rater’s opinion regarding degree of severity, whereas the current standards specify rating thresholds in actual degrees of ROM impairment. The Board must comply with the DoDI 6040.44 requirement for rating IAW the VASRD in effect at the time of separation from service. The February 2002 MEB goniometric ROM exam had slight limitation of motion, but did not mention pain with motion. Two months later, the VA C&P exam documented full ROM without any limitation. However, there was pain with motion. The Army PEB and the VA chose different coding options for the back pain condition, but both assigned a 10% rating. The Board carefully examined all evidentiary information available. The Board determined that there was insufficient evidence of significant thoracodorsal spine impairment to justify rating the thoracic spine separately, under code 5291. The treatment record also contained insufficient evidence to support a higher rating using code 5293 (intervertebral disc syndrome). As noted above, the back pain condition was rated IAW the VASRD standards that were in effect at the time of separation from service. After due deliberation, consideration of all the evidence, and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends no change from the PEB’s a rating decision of 10% for the back pain condition.

Other PEB Condition. RPPS was adjudicated by the PEB as not unfitting. This condition was not profiled, implicated in the commander’s statement or noted as failing retention standards. It was reviewed by the action officer and considered by the Board. There was no indication from the record that this condition significantly interfered with satisfactory performance of military duties. All evidence considered, there is not reasonable doubt in the CI’s favor supporting reversal of the PEB fitness adjudication for RPPS.

Remaining Conditions. Several other conditions were also noted in the Disability Evaluation System (DES) file. None of these conditions were clinically significant during the MEB/PEB period, none carried profiles and none were implicated in the commander’s statement. These conditions were reviewed by the action officer and considered by the Board. It was determined that none could be argued as unfitting and subject to separation rating. Additionally, right hip trochanteric bursitis, and other conditions were found in the VA rating decision proximal to separation, but were not documented in the DES file. The Board does not have the authority to render fitness or rating recommendations for any conditions not considered by the DES. The Board, therefore, has no reasonable basis for recommending any additional unfitting conditions for separation rating.

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. In the matter of the chronic back pain condition, the Board unanimously recommends no change in the PEB adjudication. In the matter of the bilateral retropatellar pain syndrome, or any other conditions eligible for consideration, the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation.

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

______________________________________________________________________________

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20110322, w/atchs

Exhibit B. Service Treatment Record

Exhibit C. Department of Veterans' Affairs Treatment Record

President

Physical Disability Board of Review

SFMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation

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

Deputy Assistant Secretary

(Army Review Boards)