Search Decisions

Decision Text

AF | PDBR | CY2012 | PD2012 01097
Original file (PD2012 01097.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1201097
BRANCH OF SERVICE: Army  BOARD DATE: 20131112
SEPARATION DATE: 20040112


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (91B/Animal Care Specialist) medically separated for back pain with mild muscle spasm. The CI was doing sit-ups when he felt a popping sensation in his back. In May 2001, he noted recurrent episodes of sharp pain in his back, not related to any specific activities. The back 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 right sacroiliac joint dysfunction characterized as medically unacceptable was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated back pain with mild muscle spasm as unfitting rated 10%, w ith the likely application of Army Regulation 635-40. The CI made no appeals and was medically separated.


CI CONTENTION: “My SJD worsened. Disk degeneration was added in change on my disability rating.”


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 ratings for the unfitting back pain with mild muscle spasm condition are addressed below; and, 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 20031112
 VA - based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Back Pain with Mild Muscle Spasm 5237 10% Sacroiliac Joint Dysfunction 5299-5236 20% STR
No Additional MEB/PEB Entries
Combined: 10%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200 40209 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service-connected by the Department of Veterans Affairs but not determined to be unfitting by the PEB. However the VA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on severity at the time of separation.

Back Pain with Mild Muscle Spasm Condition. The narrative summary (NARSUM) notes that the CI was experiencing low back pain (LBP) in 2001 associated with physical training. Since that time he experienced recurring pain with episodes of radiating pain into the right thigh to the knee. Pain was aggravated by running and sit-ups. Physical therapy examination on 10 February 2003 recorded normal range-of-motion (ROM) except for extension due to pain. Tests for the sacroiliac joint were positive on the right side consistent with pain complaints. Evaluation by physical medicine and rehabilitation on 23 April 2003 also demonstrated positive findings for right sacroiliac joint problems. The examiner noted mild paralumbar spasms without altered spine contour or abnormal gait. Lower extremity strength and reflexes were normal. The physician diagnosed sacroiliac joint dysfunction. On 24 June 2003, a computed axial scanning of the sacroiliac joints was normal. On a subsequent physical medicine evaluation on 16 June 2003, a facet injection resulted in good relief and the diagnosis was changed to facet syndrome. On 29 July 2003, needle nerve ablation was performed. The symptoms did not sufficiently improve for return to full duty. The MEB NARSUM completed on 23 October 2003, cited the physical medicine examination from 23 April 2003 and a ROM examination on 23 October 2003 performed by a physical medicine physician. The ROM was flexion 45, 50, 50 degrees; extension 5, 5, 10 degrees; right lateral bending 15, 15, 20 degrees; left lateral bending 10, 10, 10 degrees; right rotation 50, 50, 55 degrees and left rotation 45, 45, 50 degrees (150 combined ROM). A magnetic resonance imaging scan on 8 June 2004, 6 months after separation, showed mild left L4-5 and right L5-S1 facet joint arthrosis with normal intervertebral discs, no spinal stenosis and normal paraspinal soft tissues; confirming the diagnosis of facet syndrome.

The Board directs attention to its rating recommendation based on the above evidence. The PEB adjudicated a 10% rating coded 5237 (lumbosacral strain) with likely application of AR 635-40. The VA adjudicated a 20% rating, coded 5299-5236 (sacroiliac injury) based on the MEB NARSUM ROM examination. The ROM reported at the time of the MEB examination supports the 20% rating adjudicated by the VA in accordance with the VASRD general rating formula for diseases and injuries of the spine. There was no intervertebral disc syndrome or incapacitating episodes to support considering a higher rating under the alternate rating formula for intervertebral disc disease and 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 recommends a disability rating of 20% for the 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. In the matter of the back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a. 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
Back Pain with Mild Muscle Spasm 5237 20%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120620, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record

        
XXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXX, AR20140006115 (PD201201097)


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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

Similar Decisions

  • AF | PDBR | CY2012 | PD 2012 00970

    Original file (PD 2012 00970.txt) Auto-classification: Approved

    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 Army Board for Correction of Military Records. Next the Board considered the application of the VASRD criteria operant at the time of separation and found that the CI best fit a rating of 10% for characteristic pain on motion or for slightly limited ROM. RECOMMENDATION: The Board recommends that the CI’s prior...

  • AF | PDBR | CY2013 | PD 2013 00095

    Original file (PD 2013 00095.rtf) Auto-classification: Approved

    Despite the CI’s remarks of pain during portions of flexion of both knees, the VA C&P noted that examination of his knee on 10 June 2003 “ was grossly unremarkable” the examiner of on to state that the knee examination revealed “ no soft tissue swelling, no point tenderness, or joint effusion and there was no ligamentous instability appreciated.” After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a...

  • AF | PDBR | CY2011 | PD2011-01028

    Original file (PD2011-01028.docx) Auto-classification: Approved

    The Board evaluates VA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. The low back pain also radiated to the left buttock, hip and the upper anterior left thigh including “left sacroiliac joint pain, which is thought to be related to the low back pain.” X-rays of the lumbar spine and sacroiliac joints were normal; MRI of the...

  • AF | PDBR | CY2013 | PD-2013-02730

    Original file (PD-2013-02730.rtf) Auto-classification: Approved

    Post-Separation) ConditionCodeRatingConditionCodeRatingExam Chronic Low Back Pain523710%Strain, Thoracolumbar Spine523710%20070521Other x0 (Not in Scope)Other x 6(Not in Scope)20070521 Combined: 10%Combined:50%Derived from VA Rating Decision (VARD)dated 20070618 ( most proximate to date of separation) Chronic LBP Condition . Physical therapy ROM was TL flexion of 50 degrees (normal 90 degrees) and TL combined ROM of 152 degrees (normal 240 degrees) with ROM noted to be limited by pain.At...

  • AF | PDBR | CY2012 | PD 2012 01004

    Original file (PD 2012 01004.txt) Auto-classification: Denied

    RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201004 SEPARATION DATE: 20040129 BOARD DATE: 20130122 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, SPC/E-4, (31F/Signal Switch Operator), medically separated for chronic low back pain (LBP) without radiculopathy. Post-Separation) – All Effective Date...

  • AF | PDBR | CY2012 | PD-2012-00791

    Original file (PD-2012-00791.pdf) Auto-classification: Denied

    RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW BRANCH OF SERVICE: ARMY SEPARATION DATE: 20011029 NAME: XXXXXXXXXXXXXXXXXX CASE NUMBER: PD1200791 BOARD DATE: 20130104 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E‐4 (51T10/Tech Engineer Specialist), medically separated for chronic low back pain (LBP) secondary to right sacroiliac joint pain syndrome. The MEB forwarded the condition chronic...

  • AF | PDBR | CY2013 | PD-2013-01214

    Original file (PD-2013-01214.rtf) Auto-classification: Denied

    A physical therapy note, the next day 26 March 2004 found range-of-motion (ROM) of 75 degrees flexion and 30 degrees of extension. RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation: Physical Disability Board of Review

  • AF | PDBR | CY2014 | PD-2014-01154

    Original file (PD-2014-01154.rtf) Auto-classification: Denied

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVeterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. Examination noted normal lumbar spine ROM with pain and normal bilateral hip ROM.An orthopedic evaluation on 27 March 2009, 5 months prior to separation, noted a 16-month history of pelvic pain following pregnancy. At...

  • AF | PDBR | CY2014 | PD-2014-01932

    Original file (PD-2014-01932.rtf) Auto-classification: Approved

    The low back and left knee conditions, characterized as “chronic low back pain” and “patellofemoral pain/chondromalacia patella, left knee,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.Hypertension and bunionectomy conditions were submitted by the MEB as medically acceptable.The Informal PEB adjudicated “chronic low back pain (LBP) and chronic pain of the left knee”as unfitting, rated 10% and 0% respectively, with likely application of the VA Schedule for Rating...

  • AF | PDBR | CY2013 | PD2013 01141

    Original file (PD2013 01141.rtf) Auto-classification: Denied

    Chronic Back Condition . He complained of chronic 2/10 back pain at rest and 6/10 pain with activity and lifting. Physical Disability Board of Review