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AF | PDBR | CY2012 | PD2012 01649
Original file (PD2012 01649.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX          CASE: PD12 0 1649
BRANCH OF SERVICE: Army   BOARD DATE: 2014 0318
Separation Date: 20030605


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (73C/Finance Specialist) medically separated for back pain. The CI first reported back pain in 2001 which she attributed to lifting heavy boxes while deployed to Bosnia. This condition was treated conservatively but could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty (MOS) or physical fitness standards, so she was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). All service treatment exams referred to and treated low back pain, but the condition was characterized by the MEB as “chronic mid and upper back pain” and forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “chronic mid and upper back pain” as unfitting, rated 20%, citing criteria of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION : “My conditions was worse than what was reported. Also I was diagnosed with depression and that was never reported.


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 back condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board. The contended depression condition was not identified by the PEB so is not in the purview of this 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 PEB – Dated 20030210
VA - (4 Mos. Post-Separation)
Condition
Code Rating Condition Code Rating Exam
Chronic Mid and Upper Back Pain 5299-5295 20% Degenerative Arthritis, Sacroiliac Joint 5294-5292 10%* 20030617
No Additional MEB/PEB Entries
Other x 0
Combined: 20%
Combined: 10%
Derived from VA Rating Decision (VARD) dated 20030728.
* VARD 20050516 increased Lumbar Strain with Degenerative Arthritis, Sacroiliac Joint to 20% effective 20030606.

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 based on ratable severity at the time of separation.

Chronic Mid and Upper Back Pain Condition . There were two goniometric range - of - motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, as summarized in the chart below.

Thoracolumbar ROM
(Degrees)
MEB 5 .50 Mo. Pre-Sep VA C&P 13 days Mo. Post-Sep
Flexion (90 Normal) 85 * 80
Extension (30) 35 * 15
R Lat Flexion (30) 40 15
L Lat Flexion (30) 35 15
R Rotation (30) 40 30
L Rotation (30) 40 30
Combined (240) 275 185
Comment *pain limited; paraspinal spinal tenderness; ROM decreased secondary to pain; “constant pressure pain with spasms Right periscapular rhomboid tenderness ; tenderness over right sacro iliac joint;
§4.71a Rating 20 % 10 %
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invalid font number 31502 The CI injured her mid and upper back after lifting invalid font number 31502 a 50-pound box and carrying it invalid font number 31502 down stairs in August 2001. invalid font number 31502 She was seen by her medical provider invalid font number 31502 invalid font number 31502 for a invalid font number 31502 2- invalid font number 31502 month history invalid font number 31502 of low invalid font number 31502 back pain. invalid font number 31502 invalid font number 31502 The examiner documented physical findings of tenderness to palpation (TTP) with spasms in the paraspinal region invalid font number 31502 and pain invalid font number 31502 with full ROM. He prescribed a muscle relaxant and a non-st invalid font number 31502 eroidal anti-inflammatory drug invalid font number 31502 along with ice and stretching. A thoracolumbar spine invalid font number 31502 X invalid font number 31502 - invalid font number 31502 ray was invalid font number 31502 normal invalid font number 31502 . invalid font number 31502 invalid font number 31502 The CI was evaluated by physical therapy (PT) invalid font number 31502 invalid font number 31502 and underwent invalid font number 31502 extensive sessions of PT treatment modalities through invalid font number 31502 out 2002. A lumbosacral spine invalid font number 31502 X invalid font number 31502 - invalid font number 31502 ray was normal. The invalid font number 31502 o invalid font number 31502 rthopedi invalid font number 31502 c consultation invalid font number 31502 noted the chronic pain for invalid font number 31502 a invalid font number 31502 year which was worse with sitting or prolonged standing. There were physical findings of TTP in the right lumbar r invalid font number 31502 egions invalid font number 31502 and th invalid font number 31502 e invalid font number 31502 examiner invalid font number 31502 invalid font number 31502 gave a working invalid font number 31502 diagnos invalid font number 31502 is invalid font number 31502 invalid font number 31502 of invalid font number 31502 right sacroiliac joint dysfunction. invalid font number 31502 A right sacroiliac joint invalid font number 31502 X invalid font number 31502 - invalid font number 31502 ray was normal. A Rehabilitation Medicine examiner noted that the CI invalid font number 31502 reported pain 5/10 to 9/10, pain with standing invalid font number 31502 and sleeping invalid font number 31502 . A lumbosacral spine bone scan was normal. A lumbar spine CT scan was normal. The CI was given a permanent L3 invalid font number 31502 p invalid font number 31502 rofile for back pain with s invalid font number 31502 pecific limitations of PT at invalid font number 31502 her invalid font number 31502 own invalid font number 31502 pace and distance. The MEB invalid font number 31502 n invalid font number 31502 arrative invalid font number 31502 summary invalid font number 31502 exam invalid font number 31502 , on 23 invalid font number 31502   invalid font number 31502 December 2002, invalid font number 31502 invalid font number 31502 approximately invalid font number 31502 5 invalid font number 31502 months invalid font number 31502 invalid font number 31502 prior to separation invalid font number 31502 documented that despite medication and rest, the CI continued with constant mid and lower back pain, pressure and spasms daily invalid font number 31502 , with pain rated invalid font number 31502 5 invalid font number 31502 to 10 (on a scale of invalid font number 31502 10, invalid font number 31502 with 10 being the worst), which invalid font number 31502 increased with sitting or standing for long durations. There invalid font number 31502 were invalid font number 31502 functional limitations of an inability to invalid font number 31502 wear invalid font number 31502 a helmet, invalid font number 31502 load bearing equipment invalid font number 31502 , carry equipment greater than 10 invalid font number 31502 pounds invalid font number 31502 , do invalid font number 31502 sit-ups invalid font number 31502 /pushups invalid font number 31502 , invalid font number 31502 run a invalid font number 31502 PT test invalid font number 31502 or invalid font number 31502 fire a rifle. The MEB physical exam findings are summarized in t invalid font number 31502 he chart above. invalid font number 31502 invalid font number 31502 The invalid font number 31502 c invalid font number 31502 ommander’s invalid font number 31502 s invalid font number 31502 tatement noted that due to the CI’s invalid font number 31502 p invalid font number 31502 rofile limitations that she could not perform her MOS. invalid font number 31502 The VA Compensation and invalid font number 31502 Pension (C&P) exam invalid font number 31502 , on 17 June 2003, invalid font number 31502 invalid font number 31502 approximately invalid font number 31502 13 invalid font number 31502 days after separation noted that the CI had tenderness invalid font number 31502 over the right periscapular and rhomboid areas (near the shoulder blade) invalid font number 31502 . The examiner diagnosed sacroiliac pain on the right side, more likely than not early invalid font number 31502 degenerative invalid font number 31502 arthritis and rhomboid pain on the right side, invalid font number 31502 which was reported as invalid font number 31502 more invalid font number 31502 likely invalid font number 31502 than not musculoskeletal. The C&P physical exam findings are summarized in the chart above. invalid font number 31502
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The Board directs attenti on to its rating recommendation based on the above evidence . For a rating recommendation IAW DoDI 6040.44, t he Board must apply the 2002 VASRD coding and rating standards for the spine . The PEB coded the c hronic m id and u pper b ack p ain as 5299 ( analogous to ) - 5295 (lum bosacral strain ) and rated at 20% (w ith muscle spasm on extreme forward bending, loss of lateral s pine motion, unilateral, in standing position ) . There were no indicatio ns in the treatment record that would support the next higher rating of 40% , which would require symptoms such as listing of whole spine to opposite side, marked limitation of forward bending in standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. The VA coded as 5294 ( s acro iliac injury and weakness ) - 5292 (s pine, limitation of motion of, lumbar ) and rated at 10% ( s light ) . The 2002 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 earlier 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 Board did not find evidence of a severe impairment for a higher adjudication of 40% using alternate coding criteria. The CI was profiled for back pain and r ecords proximate to separation documented constant back pain and tenderness. At the time of the MEB, there was documentation of spasms in the paraspinal muscles (which supports the 20% rating) . After due deliberation, considering all 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 c hronic m id and u pper b ack p ain condition.


BOARD FINDINGS : 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 c hronic m id and u pper b ack p ain 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, the refore, recommends no characterization of the disability and separation determination .


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20 120918 , w/atchs
Exhib
it B. Service Treatment Record
Exhibit C. Department of Veterans
’ Affairs Treatment Record








                          
XXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review



invalid font number 31502 SAMR-RB                                                                         

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MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


invalid font number 31502 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX invalid font number 31502 , AR20140013242 (PD201201649)
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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:


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Encl                                                 
XXXXXXXXXXXXXXXXXX invalid font number 31502
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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