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AF | PDBR | CY2012 | PD2012 01694
Original file (PD2012 01694.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE : PD12 01694
BRANCH OF SERVICE: Army   BOARD DATE: 201 4 0122
Separation Date: 20020715


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (93P10, Aviation Operations Specialist) medically separated for a back condition. The injury occurred during a motor vehi cle accident (MVA) in 2000 and did not respond adequately to non-surgically treatment to meet the physical requirements of his Military Occupational Specialty (MOS) or satisf y physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Mechanical low back pain was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition w as identified by the MEB. The PEB adjudicated low back pain (LBP) condition as unfitting and rated 10% with likely application of VA Schedule for Rating Disabilities (VASRD). 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 pain condition is addressed below. Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.


 RATING COMPARISON :

Service IPEB – Dated 20020425
 VA* - (1.6 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Low Back Pain 5299-5295 10% Degenerative Disc Disease & Sclerosis of Lumbar Spine 5293 10% 20020528
No Additional MEB/PEB Entries
 Other x 2 20020528
Combined: 10%
 Combined: 10%
*Derived from VA Rating Decision (VARD) dated 20020720 (most proximate to date of separation)


ANALYSIS SUMMARY :

L ow Back Pain Condition . The CI developed LBP after a MVA in March 2000 and was seen in the Family Practice clinic for complaints of LBP the next day. He had tenderness to palpation ( TTP ) in the paravertebral muscles with full range - of - motion (ROM) . The CI was treated with a non-steroidal anti-inflammatory drug (NSAID) and physical therapy (PT). A lumbar spine X- ray demonstrated mild intervertebral disc space narrowing with mild degenerative changes at the L4-5 level. The CI attended Back class which he noted did help reduce the LBP. In January 2001, t he P hysical T herapist noted that the CI was now having difficulty running over two miles and documented physical exam findings of pain with forward flexion and TTP at L3-4. In May 2001, a n examiner noted that the CI had increased LBP worse at night when lying down or doing back movements with physical exam findings of decreased ROM with bending over . The examiner prescribed a different NSAID and put him on restricted duty for 4 weeks. In August 2001, t he CI had an other episode of acute back pain and sought emergency care for increased pain on impact and with flutter kicks. The CI was given a permanent U3 p rofile for LBP with additional restrictions of no airborne operations, no ruck marching, no flutter kicks and no running greater than two miles. The MEB narrative summary (NARSUM) exam approximately 7 months prior to separation documented that the CI had pain with movement of the spine and despite multiple courses of PT which included stretching and alternate exercise programs, the chronic LBP continued . The MEB NARSUM physical exam findings are summarized in the chart below . The commander’s statement indicated that the CI was unable to perform all the duties in his MO S without discomfort and pain.

 The VA Compensation and Pension (C&P) exam approximately 1.5 months before separation indicated that the LBP did not radiate and was not associated with other symptoms. The VA C&P physical exam findings are summarized in the chart below. There were two goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized below:

Thoracolumbar ROM (Degrees)
 PT exam ~ 7 Mo s . Pre-Sep VA C&P ~1.6 Mo s . Pre-Sep
Flexion (90 Normal)
 90 90
Extension (30)
 20 30
Combined (240)
 230 240
Comment
 Positive Painful motion Gait normal; No paraspinal muscle spasm; No muscle atrophy; Sensory & DTR normal; Neg. straight leg raise bilaterally; No painful motion or Deluca criteria
§4.71a Rating
 10% 10%

The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the LBP condition as 5295 ( l umbosacral strain ) and rated it 10% for “characteristic pain on motion” IAW the VASRD in effect at that time. The VA coded the l ow back condition as 5293 ( i ntervertebral disc syndrome ) and rated 10% based on mild recurring attacks. The PEB and the VA chose different coding options, however this did not materially affect the rating as a ll exams proximate to separation indicated pain ful motion with non-compensable ROM measurements. No appropriate coding scheme results in a rating greater than 10%. 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 LBP condition. invalid font number 31502


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 l ow 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, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
Low Back Pain 5299-5295 1 0%
COMBINED
 1 0%
invalid font number 31502

The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 120712 , w/atchs
Exhib it 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, AR20140004533 (PD201201694)

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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)


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