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AF | PDBR | CY2012 | PD2012 01698
Original file (PD2012 01698.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201698
BRANCH OF SERVICE: Army          BOARD DATE: 20130329
SEPARATION DATE: 20030612


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (77F10/Petroleum Supply Specialist) medically separated for chronic low back pain (LBP). During a field exercise in 2001, he was injured when a wrecker vehicle b acked up, slid in the mud the pe nned him between the HEMTT and the wrecker vehicle . He was admitted to the ICU for lung injury (resolved) and painful back contusions which persisted after discharge. D espite treatment, this condition did not resolve and he was unable 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 chronic LBP condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. Two PEBs both adjudicated his chronic LBP as unfitting, rated 10%, referencing Department of Defense Instruction (DoDI) 1332.39 and AR 635-40, appendix B-39. The CI made no appeals, and was medically separated with this rating.


CI CONTENTION: “I am receiving benefits for the Lumbosacral strain, minor disc bulge L4-5, in which the Army only issued me severance pay of $7740.00. Also in the process, I have been diagnosed with PTSD with marijuana dependency from the accident that caused my injury.”


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 chronic LBP condition is 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 Army Board for Correction of Military Records.


RATING COMPARISON:

Service IPEB – Dated 20030502
 VA – (7 yrs. Pre/Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain…
 5299-5295 10% Lumbosacral Strain, Minor Disc Bulge, L4-5 5237 10% 20100603
No Additional MEB/PEB Entries
 Post-Traumatic Stress Disorder (PTSD) 9411 30% 20100603
Combined: 10%
 Combined: 40%*
Derived from VA Rating Decision (VA RD ) dated 20 100924 ( most proximate to date of separation [ DOS ] ).
* VARD 20120828 increased the Lumbos acral award from 10% to 20% and awarded 10% for left lower extremity radiculopathy.




ANALYSIS SUMMARY

Chronic Low Back Pain. The narrative summary (NARSUM), 4 September 2002 noted the back pain presented in May 2001, as the result of crush injury. On 17 July 2001, X-rays of the lumbar spine were normal. Magnetic resonance imaging (MRI) of the lumbar spine, 3 July 2002, revealed L4/5 minor disc bulging, and no other findings. The CI did not experience any incapacitating episodes; denied radiation of pain, numbness, or tingling to the lower extremities. At the MEB NARSUM exam, 4 September 2002, approximately 8 months prior to separation, the CI reported persistent localized LBP that interfered with activity. Physical exam noted no muscle spasm, tenderness and discomfort with full range-of-motion (ROM) and normal reflexes, sensory, motor and gait. An addendum to the NARSUM, dated 4 September 2003, a year later, revealed no change in condition.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the condition 10% for painful motion under analogous code 5295 (lumbosacral strain). The VA rated 10% (7 years later) coded 5237, citing limitation of motion. A 20% evaluation under either code requires spasms on forward flexion, or spasms producing abnormal gait, or abnormal curvature of the spine, not supported by the evidence in record. The Board agreed there was pain on motion supporting the 10%; however, there is insufficient evidence to support the higher rating of 20% under 5295 or 5237 code. The Board considered rating under 5293; however, there was no evidence or ratable peripheral nerve impairment in this case, since no motor weakness was present and sensory symptoms had no functional implication. There was no evidence of incapacitating episodes for a rating under 5293. 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 back pain 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
 5299-5295 10%
COMBINED
 10%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120719, 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 AR20130009105 (PD201201698)

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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