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AF | PDBR | CY2012 | PD-2012-01661
Original file (PD-2012-01661.rtf) Auto-classification: Approved
RECORD OF PROCEEDING
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2012-01661
BRANCH OF SERVICE: Army  BOARD DATE: 20141209
SEPARATION DATE: 20030720


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63B/Light Wheeled Vehicle Mechanic) medically separated for low back pain (LBP). The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy all physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The back condition, characterized as “low back pain secondary to degenerative disc disease” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded three other conditions (gastroesophageal reflux disease, hypertension, and hypercholesterolemia), which were judged to meet retention standards. The Informal PEB adjudicated “low back pain with L4/L5 degenerative disc disease,” rated 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting and not rated. The CI made no appeals and was medically separated.


CI CONTENTION: “Right Shoulder - Operation Report.” In item 14, the CI also noted his service-connection for tinnitus, his upper back, and the lower back. He wrote “I request the Board to review these reports About my back became worse lately.”

His complete submission is at Exhibit A.


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 requested right shoulder condition was not identified by the PEB, and thus is not within the DoDI 6040.44 defined purview of the Board. The rating for the unfitting back condition is addressed below. 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 20030409
 VA - based on Pre-Discharge Exam or Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
LBP with L4/L5 DDD 5299-5295 10% DDD, L-Spine 5242 10% STR
Other x 0 (Not in Scope)
 Other x 4 STR
Combined: 10%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 200 30806 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The Board noted that the interim spine rules were in effect at the time of separation. The 2002 VASRD coding and rating standards for the spine, which were in effect at the time of separation, were modified on 23 September 2002 to add incapacitating episodes (5293; intervertebral disc syndrome), and then changed to the current §4.71a rating standards on 26 September 2003. The 2002 standards for rating based on range-of-motion (ROM) impairment were subject to the rater’s opinion regarding degree of severity, whereas the current standards specify rating thresholds in degrees of ROM impairment. When older cases have goniometric measurements in evidence, the Board reconciles (to the extent possible) its opinion regarding degree of severity for the older spine codes and ratings with the objective thresholds specified in the current VASRD §4.71a General Rating Formula for the Spine. This promotes uniformity of its recommendations for different cases from the same period and more conformity across dates of separation, without sacrificing compliance with the DoDI 6040.44 requirement for rating IAW the VASRD in effect at the time of separation. For the reader’s convenience, the 2002 rating codes under discussion in this case are excerpted below.

Low Back Pain Condition. The STR documents that the CI stated he initially injured his back in March 1994 after falling off a vehicle. He reinjured his back in March 1995 when he lifted a trailer hitch. A 27 March 2001 lumbar spine magnetic resonance imaging showed degenerative changes at the L4-5 disc with protrusion abutting the left L5 nerve root. A 20 September 2002 thoracic spine X-ray showed diffuse DDD changes without evidence of a displaced fracture. Lumbar spine X-rays the same day showed loss of disc height with minimal degenerative change at the L4-5 level. The line of duty determinations in the fall of 2002 attributed the LBP to the injuries in 1994 and 1995. The commander attributed the duty impairment solely to the back condition on his 1 November 2002 statement. In the 12 December 2002 MEB narrative summary, prepared 7 months prior to separation, the CI complained of LBP which had gradually gotten worse over the past 12 months. The CI failed conservative therapy and was not a surgical candidate. The physical examination was normal except for limited forward flexion and rotation of his back secondary to pain. A focused exam by orthopedics showed the CI had a normal gait and was tender to deep palpation of the mid and lower lumbar spine. Strength (5/5), sensation, position sense, and deep tendon reflexes were intact. Provocative testing of the sciatic nerve or nerve roots was negative and signs of non-organic pain were absent. Incapacitation was not documented and spasm was not recorded. The 18 December 2002 formal ROM measurements for the MEB by physical therapy (PT) are summarized in the chart below. At the 21 March 2005 (20 months after separation) spine C ompensation and P ension (C&P) exam, the CI reported mid and LBP almost all the time. He denied flare- ups, associated symptoms, or an unsteady gait. He did not use a n assistive device and was independent in all daily activities. Posture and spinal contour were normal . The ROM measurements are summarized in the chart below. The exam ination recorded evidence of painful motion, mild spasms, and vague tenderness. Repeated movement resulted in mid/ LBP at the ends of ROM , decreased ROM, and caused a mild lack of endurance. Repetition caused no increase in weakness or fatigue. The neurological exam was unremarkable. Straight leg raise tests and signs of non-organic pain were negative. A n X-ray showed mild scoliosis of upper thoracic spine. The ROM evaluations in evidence which the Board weighed in its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)
 MEB ~ 7 Mo. Pre-Sep PT ~7 Mo. Pre-Sep VA C&P ~20 Mo. Post-Sep
Flexion (90 Normal)
 Limited 55 (Passive 110) 80
Combined (240)
 # 120 220
Comment
 Consult to PT for formal ROM Formal ROM for MEB - l umbar spine No goniometer specified – thoracolumbar spine
§4.71a Rating
 --- 20 % (New spine rules) 10 %

The Board direct ed it s attention to its rating recommendation based on the above evidence. The PEB rated the LBP condition at 10% (VASRD code 5299-5295; rating by analogy - l umbosacral strain: with characteristic pain on motion) citing pain with motion ( 5295 was revised and moved to 5235–5243 on 26 September 2003) . The VA rated the LBP condition at 10% , coded 5242 ( d egenerative arthritis of the spine ) citing ROM. The criteria for rating diseases and injuries of the spine apply with or without symptoms such as pain (whether or not it radiates), stiff n ess, or aching in the area of the spine affected by residuals of injury or disease. A t the time of the MEB exam , the limitation of motion supported a 20% rating for a moderate loss of motion under the interim rules using the old code 5292 . The Board noted that it was also consistent with a 20% rating under the new spine rules. The VA C&P exam , which was well outside the normal 12 - month window for higher probative value, supported a 10% rating under the new (current) spine rules . The CI was adjudicated under the interim spine rules , which were in effect at the time of separation . The Board found no route to a higher rating under any code at the time of separation. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the LBP conditi on .


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 LBP condition, the Board, by a majority vote, recommends a disability rating of 20%, coded 5292 IAW VASRD §4.71a. The single voter for dissent did not elect to submit a minority opinion. 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 Condition 5292 20%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120914, 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, AR20150006335 (PD201201661)


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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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