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AF | PDBR | CY2012 | PD2012 00515
Original file (PD2012 00515.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1200515
BRANCH OF SERVICE: Army  BOARD DATE: 20131106
Date of SEPARATION: 20021002


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63B10/Light Wheel Mechanic) medically separated for chronic low back pain (LBP), right wrist pain and chronic anterior chest pain. Her LBP began in March of 1995 during Advance Individual Training after a fall during a low crawl exercise. In 1999 she developed a ganglion cyst on her right wrist that was removed surgically in March 2001 and her chest pain developed after an atrial/septal defect repair in 1997. The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent U3/L3/H2/S3 profile and referred for a Medical Evaluation Board (MEB). The back, wrist and chest conditions, characterized as “chronic low back pain,” “right radial wrist pain status post radial artery ligation” and “chronic anterior chest wall pain secondary to atrial septal defect repair,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded four other conditions (right patellar tendinitis, migraine without aura, conductive and sensorineural hearing loss and decreased night vision in the right eye), as well as an AXIS I dysthymia condition for PEB adjudication. The Informal PEB (IPEB) adjudicated the low back, right wrist and anterior chest pain conditions as unfitting, rated 10%, 0% and existed prior to service (EPTS) respectively, referencing the US Army Physical Disability Agency (USAPDA) pain policy for the rating of the wrist. The remaining conditions were determined to be not unfitting and therefore not ratable. The CI appealed to the Formal PEB (FPEB) which determined that the right wrist pain was more appropriately rated at 10% using the same coding as the IPEB. The combined rating was therefore changed to 20%.


CI CONTENTION: “I do not feel that the injuries and surgeries was looked at. I am dealing with my child dieing inside me then open heart surgery 4 mons later. Plus all the other injuries. When I was hospitalized for depression no one checked up on me. I was walking infront of moving vehicles! I did go through a hostile and sexual incident that I did not let the Army know about. My doctor at the VA hospital knows. I did not realize this could be partly why I have tremors and have issues sleeping. I lost almost all contact with my friends. I tried so hard to stay in and deployed to support Bosnia after the baby and heart surgery.”


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 applicant. The ratings for the unfitting back, right wrist and chest conditions are addressed below. The requested chronic anterior chest condition is eligible for Board review to the extent that, although the Board does not have the authority to recommend a reversal of the EPTS determination; it, by precedent and prior legal/administrative opinion, may review the fairness of the PEB’s judgment that there was not permanent service aggravation. Should the majority of members agree that there was permanent service aggravation; a disability rating IAW the Veterans Affairs Schedule for Rating Disabilities (VASRD), with or without a deduction IAW VASRD §4.22 (rating of disabilities aggravated by active service), will be recommended. The Board acknowledges the CI’s implied contention for ratings of her right knee, migraine, hearing loss, decreased night vision and dysthymia (depression) conditions which were determined to be not unfitting by the PEB; and, emphasizes that disability compensation may only be offered for those conditions that cut short the member’s career. Should the Board judge that any contended condition was most likely incompatible with the specific duty requirements; a disability rating IAW the VASRD, and based on the degree of disability evidenced at separation, will be recommended. The implied hip condition was not identified by the PEB, and thus not within the DoDI 6040.44 defined purview of the Board. The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected conditions continues to burden her; but, must emphasize that the Disability Evaluation System (DES) has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. 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 FPEB – Dated 20020614
 VA - (2 Mos. Pre -Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain 5295 10% Back Pain; Multilevel DDD 5292 20% 20020809
Rt Wrist Pain 5099-5003 10% S/P Rt Wrist Ganglion Cyst 5299-5024 10% 20020809
Rt Hand Pain w/ Intermittent Paresthesias Assoc w/ S/P Rt Wrist Ganglion Cyst Excision 8616 10% 20020809
Chronic Anterior Chest Pain 5099-5003 EPTS S/P Atrial Septal Defect Repair w/ Chronic Chest Pains 5399-5321 10% 20020809
Rt Patellar Tendinitis Not Unfitting Rt Knee Retropatellar Pain 5299-5014 10% 20020809
Migraine w/out Aura Not Unfitting No Corresponding VA Entry
Hearing Loss Not Unfitting Lt Ear Hearing Loss 6100 0% 20020802
Rt Ear Hearing Loss 6100 NSC 20020802
Decr Night Vision Rt Eye Not Unfitting No Corresponding VA Entry
Dysthymia Not Unfitting Major Depression 9434 30% 20020809
No Additional MEB/PEB Entries
 Other x 4 20020809
Combined: 20%
 Combined: 80%
Derived from VA Rating Decision (VA RD ) dated 200 30523 ( VARD available most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:
Chronic Low Back Pain. The applicant experienced intermittent LBP since initial training in 1995. Magnetic resonance imaging (MRI) of the lumbar spine on 29 October 1999 was normal except for minimal degenerative change of the T12-L1 disc manifested by desiccation without loss of disc height, protrusion or herniation. There was no narrowing of neural spaces. Incidental developmental findings of no clinical significance were noted (Schmorl’s nodes of L2 and L3 vertebral bodies). At a clinic follow up on 16 November 1999 a 4 year history of intermittent LBP was noted with a baseline of minimal pain. There were occasional episodes of locking up without leg pain, numbness or paresthesia. On examination there was full range of back motion with normal spinal contour. There was no spasm and strength and reflexes were normal. The CI became pregnant and delivered her baby in August 2000. At a 20 February 2001 clinic encounter, the provider discussed the MOS Medical Retention Board (MMRB) process noting back pain as well as wrist pain and chest pain (discussed below). Available service treatment records (STRs) for the years 2000 and 2001 are silent with regard to care for recurrent LBP. The CI’s Army Physical Fitness Test (APFT) record shows she passed the APFT on 15 August 2001 performing all three tasks (sit-ups, push-ups and the two mile run). The CI met the MMRB on 15 January 2002. The commander’s letter to the MMRB dated 3 January 2002, mentions chest pain and wrist pain but makes no mention of back pain. The MMRB proceeding on 15 January 2002 refer to chest pain and hand pain but makes no mention of back pain. The MMRB concluded the CI should be referred into the DES. The commander’s letter to the PEB dated 4 February 2002, mentions chest pain and wrist pain but makes no mention of back pain and noted she could do the two mile run for the APFT. A physical therapy range-of-motion (ROM) examination for the MEB performed on 12 February 2002, recorded lumbar ROM as: flexion 36 degrees, extension 15 degrees, and side bending of 10 degrees to the right and 12 degrees to the left. According to the 13 February 2002 orthopedic MEB narrative summary (NARSUM), ever since the initial injury while in training in 1995 her back had been hurting (characterized as aching) on both sides of the para-lumbar region with occasional radiation to the neck. The CI reported that “The severity of her pain is 8 to 9 out of 10, lasting from 2 weeks to one month straight several times per year since 1995.” Her back pain was aggravated by sitting, laying and rucksack marching. There had been no improvement in the pain with treatment (rest, medication, physical therapy). On examination there was no tenderness or muscle spasm. Posture, spinal contour and gait were normal. On forward flexion the CI could reach fingertips to within 10 centimeters (4 inches) of the floor. Motion in other directions was stated to be normal. On 11 February 2002, a neurology examination recorded a normal gait and normal lower extremity strength, sensation and reflexes. The MEB NARSUM exam on 18 April 2002 recorded a history of chronic lumbar back pain ever since a fall in training without radicular symptoms or lower extremity weakness. The NARSUM records, “She states she has been able to perform physical fitness training with her unit which has not dramatically worsened these symptoms.” At the end of the NARSUM, in the present condition section, the examiner noted that the CI stated she was unable to lift objects exceeding 30 pounds, perform aerobic conditioning exercises other than walking and swimming, perform push-ups, march, wear load bearing equipment or backpack, and unable to carry a rifle or fire a rifle, limitations that were referred to in the initial section describing the chronic chest pain (discussed below). The examination section of the NARSUM recorded lumbar ROM results that were from the physical therapy examination noted above (exact same values; flexion 36 degrees, extension 15 degrees, right side bending of 10 degrees and left side bending of 12 degrees). There was minimal tenderness to palpation and no radicular signs or symptoms on provocative testing. The IPEB on 21 May 2002 and the FPEB on 14 June 2002. The CI sought care on 4 June 2002 for recurrent acute back pain of 24 hours duration. The examiner reported the presence of spasm on examination. Lumbar flexion was 45 degrees, extension 10 degrees and lateral bending 10 degrees. On follow-up for the acute back pain exacerbation on 11 June 2002, the CI reported the presence of a back deformity for 2 years however X-rays of the lumbar spine obtained on 13 February 2002 were normal with normal alignment and normal vertebral body heights. Back flexion was recorded as 30 degrees, but lateral flexion was improved to 20 degrees and symmetric. A repeat MRI of the lumbar spine on 18 June 2002 was unchanged from the examination performed in October 1999 showing the minimal T12-T1 disc degenerative change (desiccation) without significant disc changes or neural space narrowing. Minimal facet degenerative change was noted from L3 to S1. The CI sought care again on 10 July 2002 for recurrent LBP since the day prior. On examination, she was in no distress and had mild tenderness. Follow up care on 12 July, 17 July and 18 July 2002 noted back spasm with tenderness and decreased motion. Gait was normal. At the VA Compensation and Pension (C&P) examination on 9 August 2002, 2 months prior to separation, the CI reported lifting was limited to 30 pounds and that she had radicular symptoms intermittently going down both legs. On exam she had normal gait. She had tenderness in the muscles adjacent to the spine. The examiner reported ROM of the lumbar spine with flexion 40 degrees, extension 20 degrees, lateral bending 20 degrees both sides and rotation 20 degrees both sides.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated 10% using the code for lumbosacral strain 5295, citing “minor loss of motion due to pain, no radiculopathy or chronic spasm noted, although occasional transient spasms are acknowledged.” The VA rated the condition 20% using the code for limitation of lumbar spine (5292) later changed to 5237 (lumbosacral strain) concordant with the updated VASRD spine guidelines effective at the end of 2003. In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation. The Board notes that the 2002 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards effective 26 September 2003. The Board must correlate the above clinical data with the 2002 rating schedule, in which the applicable diagnostic codes include 5292 (limitation of lumbar spine motion), 5293 (intervertebral disc syndrome, incapacitating episodes) and 5295 (lumbosacral strain). The Board considered the ROM examinations in evidence for rating under the 2002 VASRD diagnostic code 5292, limitation of lumbar spine motion (slight, moderate, severe). The physical therapist on 12 February 2002 specified lumbar ROM with flexion of 36 degrees. The orthopedic examination performed a day after the physical therapy examination, recorded trunk flexion with finger tips reaching to 10 centimeters (4 inches) of the floor which reflect a near normal combined thoracic spine and lumbar spine flexion of approximately 90 degrees for the CI’s height (65 inches). The isolated lumbar flexion reported by the physical therapist is consistent with the truck flexion reported by the orthopedic surgeon. The Board noted the C&P examiner also reported lumbar ROM with results of 40 degrees of flexion, somewhat improved when compared with the physical therapy examination (also improved in lateral bending and extension). Under the VASRD guidelines in effect at the time, there were separate codes for limitation of motion of the lumbar spine and dorsal (thoracic) spine, therefore the Board concluded the VA examiner was performing the examination consistent with the VASRD in effect at that time and reported lumbar motion and not combined thoracolumbar motion which was introduced into the VASRD in September 2003. Although the lumbar flexion was slightly reduced, the near normal MRI and ability to reach the fingertips to within four inches to the floor, as documented by the orthopedic examination, was concluded to more nearly approximate the slight limitation of motion than the moderate limitation of motion under 5292. The Board concluded the preponderance of evidence supported no higher than a 10% rating under 5292, limitation of lumbar spine motion. The Board next considered the rating under the code 5295, lumbosacral strain, utilized by the PEB. The Board agreed there was sufficient evidence of characteristic pain on motion to support the 10% rating adjudicated by the PEB. The Board noted the examination findings of spasm on examinations after the FPEB, but noted there was no unilateral loss of lateral spine motion and the gait was normal with ROM similar to other examinations. Review of the STR reflected a chronic pattern of intermittent back pain since 1997 with periodic exacerbations with infrequent medical care until after entry into the DES. The Board concluded that the preponderance of evidence did not support a rating higher than the 10% rating assigned by the PEB. The Board then considered whether a higher rating was warranted under the guidelines for intervertebral disc syndrome, code 5293, based on incapacitating episodes requiring bed rest prescribed by a physician. The MRIs did not document the presence of intervertebral disc disease and clinical records documented absence of radicular signs and symptoms. There was no evidence of bed rest prescribed by a physician that would support consideration of a minimum rating under this code. There was no associated radiculopathy for separate peripheral nerve rating. 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 low back condition.

Right Wrist Condition. The CI (who is right hand dominant) underwent surgical removal of painful ganglion cysts from her right wrist in November 1999 and again in March 2001. During the first surgery, the radial artery was ligated however blood flow through the ulnar artery provided full circulation to the hand. The CI continued to have pain in the affected area after the surgeries with associated subjective complaints of numbness. Evaluation by a hand surgeon in July 2001 noted intact vascular function, full ROM with reduced grip strength of 4/5. The surgeon thought the symptoms were due to scar formation. Electrodiagnostic studies performed on 18 April 2012, demonstrated normal peripheral nerve function. Physical therapy ROM examination on 12 February 2002, recorded right wrist ROM that was essentially the same as the unaffected left wrist (flexion 70 degrees versus 75 on the left; extension 85 versus 80 on the left; radial deviation 30 in both and ulnar deviation 35 in both). Both the orthopedic MEB NARSUM on 13 February 2002 and the general MEB NARSUM on 18 April 2002, noted complaints of pain and numbness with repetitive activity. The orthopedic NARSUM examination noted the presence of a large surgical scar over the volar (palmar) surface of the wrist with numbness around the surgical site. Sensation in the fingers was intact. The strength of the fingers and thumb was normal (5/5) and vascular circulation was normal. The 18 April 2002 MEB NARSUM noted a stable examination and recorded ROM results identical to the physical therapy examination. At the C&P examination on 9 August 2002, 2 months prior to separation, the CI reported aching pain in the area of the wrist surgery. On exam, she had tenderness to palpation over the area, but had normal sensation "(no evidence of dysesthesia).” Painful motion was noted with flexion of 30 degrees, extension 30 degrees, radial deviation 10 degrees and ulnar deviation 20 degrees.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated 10% citing painful motion coded analogously for arthritis (5099-5003) citing pain with likely application of the USAPDA pain policy but was otherwise consistent with guidelines under 5003. The VA gave separate ratings for the pain and numbness; they gave 10% citing loss of motion and painful motion dual coded 5299-5024 (analogously for tenosynovitis) and 10% for numbness coded 8616 (neuritis). Even though there was a significant discrepancy between the ROM from the MEB and C&P evaluations, the rating is not affected regardless since there is no compensable loss of motion under either measurement. The Board agreed that application of VASRD §4.59 (painful motion) or §4.40 (functional loss) would support a rating of 10% coded 5099-5003 (analogously for arthritis). The Board then considered whether an additional rating could be recommended under a peripheral nerve code, as conferred by the VA, for the associated numbness at separation. Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating to disability. The sensory component in this case was a subjective finding as the objective electrodiagnostic testing revealed no sensory abnormalities and had no functional implications and no motor weakness was in evidence. There is thus no evidence of a separately ratable functional impairment (with fitness implications) from the residual scar site numbness; and, the Board cannot support a recommendation for an additional disability rating on this basis. Furthermore, any related functional impairment was considered in the overall 10% rating described above. 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 right wrist condition.

Chronic Anterior Chest Pain Condition. The CI underwent open heart surgery in April 1997 to repair a congenital heart condition: atrial septal defect. After surgical convalescence, the CI developed chronic chest wall pain preventing vigorous military duties. Medical evaluation established no etiology other than post-operative chest wall pain. The MEB NARSUM examination recorded chest pain with vigorous activity (push-ups, heavy lifting, carrying a rucksack) and certain arm movements.

The Board directs attention to its rating recommendation based on the above evidence. The PEB adjudicated that the condition EPTS and that there was no permanent service aggravation and thus was not compensable; “Chronic anterior chest pain following heart surgery (atrial septal defect repair - EPTS condition). No evidence of permanent service aggravation, not an unexpected adverse result of surgery for a congenital condition, not compensable. Unfitting due to pain.” In accordance with DoDI 1332.38; “E3.P4.5.6. Treatment of Pre-Existing Conditions. Generally recognized risks associated with treating preexisting conditions shall not be considered service aggravation.” The Board noted that this is a congenital condition that often requires correction via open heart surgery. The anterior chest pain that the CI developed is an expected residual of the surgery. While this pain precluded the CI from performing her military duties, there was no indication from the record that the CI's military duties aggravated the condition beyond its natural progression or unexpected result from open heart surgery. After due deliberation in consideration of the preponderance of the evidence, members agreed that there was insufficient cause to recommend a change in the PEB’s determination for the chest pain condition following surgical repair of a congenital heart condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the right patellar tendonitis, migraine without aura, conductive and sensorineural hearing loss, decreased night vision right eye and dysthymia were not unfitting. 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. Dysthymia. At the time of the MEB examination, the CI completed DD Form 2807 on 23 January 2002 and checked “yes” to question 17 regarding depression and counseling. In explanation she wrote “In 2000 I was hospitalized because of depression.” The examiner wrote: “Hospitalized X 1 week – depression” without further comments. No current symptoms or problems were noted however the CI underwent MEB psychiatry evaluation on 14 February 2002. The CI reported that depression symptoms had been present continuously since 1996 and that she had avoided treatment to be a good soldier. Hospitalization in 1999 for an episode of suicidal ideation was noted with diagnosis of adjustment disorder. At the time of the MEB psychiatry evaluation in February 2002, the mental status examination was normal without suicidal ideation, and the diagnosis was dysthymia. The commander’s letter dated 4 February 2002 mentions chest pain and wrist pain without mention of any psychological symptoms interfering with duty. The CI’s profile was updated 10 May 2002 with diagnosis of dysthymia and an S3 profile. A psychiatry addendum 12 June 2002 changed the diagnosis to recurrent major depressive disorder and indicated the CI had recently begun medication treatment (in February 2002). Another psychiatry addendum, 17 June 2002, requested by the CI noted the chronic depressive symptoms since 1996 with continued suicidal thoughts. Based on reported symptoms, the psychiatrist stated the CI was unable to perform duties. Review indicates STRs are silent with regard to treatment for depressive symptoms and that profiles prior to referral into the DES were S1 for no restrictions for psychological symptoms. The Board discussed the letter from the psychiatrist that was submitted at time of PEB appeal which recommended a profile to prevent the CI from handling weapons or ammunition. However, the prior to PEB STRs and the commander's statement do not document the psychiatric condition as a basis for precluding the CI from performing her military duties. Other contended. The MEB NARSUM notes a history of right knee pain since 1996 diagnosed as right patellar tendonitis. Examination of the knee was normal and gait was normal. At the time of the MEB examination, the CI reported a history of headaches for which she self treated with over the counter medications. The CI had hearing loss with a non-disqualifying H2 profile (no duty restrictions). At the MEB examination, a history of eye exposure to diesel fuel in 1999 was noted with residual sensitivity. Visual acuity was normal. None of the conditions were profiled, none were implicated in the commander’s statement and none were judged to fail retention standards. All were reviewed and considered by the Board. Though the STRs document treatment for all of these conditions, there was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance. After due deliberation 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 any of the contended conditions and so 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. As discussed above, PEB reliance on the USAPDA pain policy for rating the right wrist pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the right wrist condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the chronic anterior chest pain condition, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended right patellar tendonitis, migraine without aura, conductive and sensorineural hearing loss, decreased night vision right eye and dysthymia conditions, the Board unanimously recommends no change from the PEB determinations of 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 recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Low Back Pain 5295 10%
Right Wrist Pain 5099-5003 10%
Chronic Anterior Chest Pain EPTS --
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120603, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





XXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review


SFMR-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 XXXXXXXXXXXXXXXXXXXXXXXXX, AR20140002039 (PD201200515)


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
                                                      (Army Review Boards)


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