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AF | PDBR | CY2012 | PD 2012 00458
Original file (PD 2012 00458.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2012-00458
BRANCH OF SERVICE: Army  BOARD DATE: 20150122
SEPARATION DATE: 20030620


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (91J10/Quartermaster, Chemical Equipment Repair) medically separated for lumbar spine condition. 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 lumbar spine condition, characterized as “myofascial low back pain (LBP) syndrome” and “degenerative arthritis of the lumbar spine,” were forwarded to the Physical Evaluation Board (PEB). The MEB also identified and forwarded one other condition “moderate obstructive sleep apnea,” as medically acceptable, IAW AR 40-501. The Informal PEB adjudicated “myofasical low back pain syndrome with L3-L4 degenerative changes” as unfitting, rated 10% with likely application of the VA Schedule for Rating Disabilities (VASRD). The remaining condition w as determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: The CI elaborated no specific contention in his 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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting lumbar spine condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20030415
 VA – Based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Myofascial Low Back Pain w/ L3-L4 Degenerative Changes 5299-5295 10% Myofascial Lower Back Pain 5021-5295 10% STR
Other x0
 Other x4 (Not in Scope)
Rating: 10%
 Combined: 10%
Derived from VA Rating Decision (VA RD ) dated 200 30829 (most proximate to date of separation [ DOS ] )


ANALYSIS SUMMARY: IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board reviews medical records and other available evidence to assess the fairness of PEB rating determinations, using the VASRD standards, based on ratable severity at the time of separation.

Myofascial Low Back Pain Syndrome with L3-L4 Degenerative Changes Condition. The CI had chronic LBP for over a 3-year period without the identification of an inciting injury. He was treated with physical therapy, non-steroidal anti-inflammatory drugs, low dose anti-depressant medication, and restricted duty without a resolution of the pain. There was reference made to an X-ray of the back that noted a diagnosis of osteoarthritis at L3-4; however, the primary document was not present for Board review. The STR contained lumbar spine active range-of-motion (ROM) measurements accomplished 3 months prior to separation, which documented a forward flexion of 25 degrees (normal documented as “40⁰-60⁰”) using a “universal inclinometer.” The narrative summary (NARSUM) noted the CI was unable to stand or sit for prolonged periods, run, wear a kevlar helmet, jump, road march, or lift greater that 10-20 pounds without exacerbating his pain. The pain and stiffness also affected his sleep and daily activities. The physical exam revealed mild limitation in ROM with pain and tenderness to palpation along the lumbar paraspinal muscles. He had a negative straight leg raise with normal strength, sensation and reflexes. There was no VA Compensation & Pension exam performed and the VA rating was based on the STRs.

The Board directs attention to its rating recommendation based on the above evidence. The PEB and the VA both applied VASRD code 5295 (lumbosacral strain), and both granted a 10% evaluation for the myofascial LBP condition based on the STR. The 2003 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

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 earlier ROM based criteria were subject to the rater’s opinion regarding degree of severity, as opposed to the more objective current standards with quantifiable rating thresholds grounded in ROM measurements. The NARSUM examiner described the CI’s ROM limitation as “mild” which would correspond to the 10% rating under code 5292. The lumbar ROM of 25 degrees would correlate to either a 10% or 20% evaluation; however, that exam does not meet VASRD §4.46 (Accurate measurement), because the examiner used a “universal inclinometer” instead of a goniometer as specified in §4.46. Coding under the 5295 code would result in a 10% evaluation (as applied by the PEB & VA) as there was characteristic pain on motion without documentation of any muscle spasm. 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 myofascial LBP syndrome 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 myofascial LBP syndrome and IAW VASRD §4.71a, 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 re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20141105, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record



                 
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX , AR20150003719 (PD201200458)
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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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