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AF | PDBR | CY2012 | PD2012 01013
Original file (PD2012 01013.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201013
BRANCH OF SERVICE: Army  BOARD DATE: 20130718
SEPARATION DATE: 20030814


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (13E/Cannon Fire Direction Specialist) medically separated for chronic low back pain (LBP). He strained his back while changing HUMVEE tires in 2002. Conservative treatment (medications, physical therapy [PT], chiropractic manipulation and percutaneous electrical nerve stimulation [TENS]) failed to improve his pain. His back condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The back and associated joint pain conditions, characterized as “chronic low back pain” and “bilateral sacroiliac joint pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded three other conditions (left knee pain, bilateral pes planus, and right shoulder pain) for PEB adjudication. The PEB adjudicated the back and sacroiliac joint (SIJ) conditions as “chronic low back pain” and determined it to be unfitting, rated 10%. The remaining conditions were 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 low back 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 20030326
 VA - (11+ Wks Pre-Separation) VARD Dated 20030815
Condition
 Code Rating Condition Code Rating Exam
Chronic low back pain (LOD) and bilateral sacroiliac joint pain with negative imaging studies for the Lumbosacral spine and S1 joints. 5299-5295 10% Lumbar Spondylosis with Transitional Vertebra and Chronic Sacroiliitis, and Degenerative Arthritis of Bilateral Feet 5003 10% 20030523
Left knee pain status post arthroscopic lateral meniscus repair Not Unfitting Left Knee Repair With Chondromalacia 5099-5019 0% 20030523
No Additional MEB/PEB Entries
 4 x 0% (Including above); 2 X NSC 20030523
Combined: 10%
 Combined: 10%
Derived from VA Rating Decision (VA RD ) dated 200 30515 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY: The 2002 Veterans Affairs Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine were changed to an interim §4.71a rating standard effective 23 September 2002 and were in effect at the time of his separation. Five weeks after his separation, the current VASRD rating standards came into effect on 26 September 2003, including a table for thoracolumbar range-of-motion (ROM). The 2002 standards for rating are based on the rater’s interpretation and opinion of ROM impairment regarding degree of severity, whereas the current standards specify rating thresholds in degrees of ROM impairment measured with an instrument and following a table.

Chronic Low Back Pain Condition. The CI had intractable LBP after he lifted a heavy object at work in May 2002. X-rays and magnetic resonance imaging of the lumbar spine were normal other than a congenital incomplete fusion of the L1 transverse process. He was treated with medications and PT without resolution of his LBP and then referred to Physical Medicine and Rehabilitation (PMR) for a trial of TENS; it also failed to improve his pain as did chiropractic manipulation. He was placed on a permanent L3 profile on 10 January 2003 for “chronic back pain” with restrictions on unit running, jumping and ruck marching, and an MEB was initiated. The CI’s Battalion commander’s evaluation on 3 March 2003 noted him “unfit for duty in a combat arms organization” and that the “limits of his profile most likely will keep him from performing fully in any assigned MOS.” The CI’s Company commander stated the CI “experiences pain, limited motion and this has made even everyday activities difficult. (He) has not been to the field with this battalion since his arrival to the unit.”

In the narrative summary, dictated 10 February 2003, 6 months prior to separation, the CI reported "I have torn ligaments and muscles in my back.” The MEB examination was a summation of a February 2003 medical examination, a February 2003 physical therapy consult and a November 2002 PMR examination. The spine was in line without step-offs or-deviations and there was tenderness to palpation of the lumbar and bilateral SI joint area with positive muscle guarding. The examiner noted axial compression produced lower lumbar pain, a sign of non-organic pain. The neurological exam was essentially normal. A focused examination by PMR in November 2002 showed no muscle spasms with minimal tenderness over the lower lumbar and sacroiliac joint of the left hip and his neurological examination was normal. Provocative testing of the hips and lower back was negative and lower extremity strength was normal.

At the VA Compensation and Pension (C&P) exam, performed about 3 months prior to separation, the examiner stated the review of systems as “In general, he can sustain heavy physical activities without immediate distress.” The VA examiner noted normal posture and gait and that the curvature of the lumbosacral spine was maintained without spasm. No muscle atrophy was identified in the back, buttock, or lower extremities. There was no radiation pain on movement. The ROM was within normal limits and occurred without restriction or pain. The examiner also stated pain, weakness, lack of endurance, fatigue, or incoordination did not impact further on the ROM. The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.
L umbar ROM( Normal in Degrees)
 PT ~10 Mo. Pre-Sep “Back Exam” (20021001) Physical Medicine and Rehabilitation “Back” exam
~9 Mo. Pre-Sep (20021114)
MEB ~ 6 Mo. Pre-Sep based on PT ROM (20030212) VA C&P ~ 3 MOS . Pre-Sep
(20030523)
Flexion (90)
 70 90 80 90 (95)
Extension (30)
 10 10 10 30 (35)
R Lat Flexion (30)
 20 20 25 30 (40)
L Lat Flexion (30)
 30 30 25 30 (40)
R Rotation (30)
 - - 40 30 (35)
L Rotation (30)
 - - 35 30 (35)
Combined (240)
 NA NA 200 240 ( 240)
Comment
 Pain w/ prolonged walking/standing. No bowel or bladder dysfunction or radiating symptoms. Negative SLR. LE motor strength 5/5 throughout. Sensory intact. No muscle spasms with minimal tenderness over lower lumbar & sacroiliac joint. N eurological exam was normal. Neg Patrick/Faber test. LE strength normal. TTP @ lumbar & bilateral SI joint area. Positive-muscle guarding. Axial compression produced lower lumbar pain. ( SLR test, DTRs, Strength , light touch, clonus exam and Babinski's w ere described as normal) Curvature of LS spine maintained & para- spinal muscles were not in spasm. No muscle atrophy. No radiation pain on movement. ROM WNL & occurs w/o restriction or pain. Pain, weakness, lack of endurance, fatigue or incoordination does not impact further on the range of motion.
§4.71a Rating
 10 % 0-10% 10 % 0 %

The Board directed attention to its rating recommendation based on the above evidence. The PEB coded 5299-5295 for lumbosacral strain, and rated for pain on motion. The VA coded 5003, for arthritis and assigned 10% for X-ray evidence of involvement of multiple joints in the absence of painful or limited motion. The Board reviewed the examinations in evidence above and found the VA exam most proximate to separation and with tabulated normal ROM to have the most probative value; however, the Board noted that the PEB examination, 3 months earlier, was also complete and had compensable loss of motion. At the VA examination, the CI had painless ROM and negative De Luca testing with normal (non-compensable) lumbar ROM. The subjective complaint of pain cannot be applied separately to the SIJ and back without violation of VASRD §4.14 (avoidance of pyramiding.) Both the PEB and VA combined the two conditions for rating. The Board noted that while the abnormal X-ray reports, cited by the C&P examiner, were not in the records in evidence, these were well described in the C&P narrative. The Board determined that the actual reports were not necessary for adjudication of the case. A 10% disability rating can be supported by either the limitation in motion noted by the PEB or by the painful motion with radiographic abnormalities cited in the C&P examination. The Board considered other coding options and found none which provided a rating advantage to the CI. The ROM was normal and painless on the C&P examination; there were no incapacitating episodes. The Board also noted that on subsequent VA rating decisions, the CI reported being employed in manual labor for several years after separation including farming, roofing, landscaping, and construction work. 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 chronic LBP 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 chronic LBP condition 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 recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic low back pain (LOD) and bilateral sacroiliac joint pain 5299-5295 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120612, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130018149 (PD201201013)

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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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