RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY
CASE NUMBER: PD1200546 SEPARATION DATE: 20030327
BOARD DATE: 20130118
SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this
covered individual (CI) was an active duty SPC/E‐4 (71L/Administrative Specialist), medically
separated for chronic low back pain (LBP). The CI developed LBP following a lumbar puncture
done during an evaluation for a peripheral neuropathy. The CI did not improve adequately with
conservative treatment to meet the physical requirements of her Military Occupational
Specialty or satisfy physical fitness standards. She was issued a permanent P3L3 profile and
referred for a Medical Evaluation Board (MEB). The MEB forwarded the LBP condition to the
Physical Evaluation Board (PEB) as a medically unacceptable condition. Demyelinating more
than axonal sensorimotor neuropathy condition, identified in the rating chart below, was also
determined by the MEB to be medically unacceptable. The PEB adjudicated the low back
condition as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating
Disabilities (VASRD). The neuropathy condition was determined to be not unfitting. The CI
made no appeals and was medically separated with a 10% disability rating.
CI CONTENTION: The CI elaborated no specific contention in her application.
SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI
6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined
by the PEB to be specifically unfitting for continued military service; or, when requested by the
CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings
for unfitting conditions will be reviewed in all cases. 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:
VA (2 Mos. Post‐Separation) – All Effective Date 20030328
Code
Condition
Chronic low back strain
5295
NO VA ENTRY until 20070321 VARD*
Scar, Left Ear
7800
0% X 1 / Not Service‐Connected x 0
Combined: 20%
Service IPEB – Dated 20030129
Condition
Chronic low back pain
Demyelinating…neuropathy Not Unfitting
↓No Addi(cid:415)onal MEB/PEB Entries↓
Combined: 10%
*The VA granted service connection peripheral neuropathy effective 20070321 rated at 0%.
**VARD dated 20080604, Clear and Unmistakable error. Right ear 30% and left ear 10%, both effective 20030328.
ANALYSIS SUMMARY:
Low Back Condition. The CI developed a sensorimotor neuropathy after a series of vaccinations
during initial training. As part of the diagnostic evaluation, she underwent a lumbar puncture
(LP) on 1 February 2000. She was seen the next day stating that she had had a headache and
LBP since the LP. The headache resolved, but she continued to have LBP about the site of the
LP. Both X‐rays and magnetic resonance imaging were normal. Despite duty limitations,
Rating
10%
Exam
20030527
Code
5299‐5295
Rating
10%
10%**
20030527
20030527
physical therapy and medications, she could not meet full duty requirements and was referred
to an MEB. A neurological evaluation was performed on 7 November 2002 (almost 5 months
prior to separation) for the MEB; it noted that she could not do push‐ups secondary to the LBP.
Strength and reflexes were normal. Sensation was normal except for decreased temperature
and pinprick sensation in the right lower extremity. Gait was normal. At the MEB examination
on 6 December 2002, the CI reported continued LBP. The examiner noted mild tenderness to
palpation over the left sacroiliac joint and lumbosacral spine. The neurological examination
was normal. The MEB narrative summary was dictated on 9 December 2002, (less than 4
months prior to separation). The CI reported that the pain did not radiate to the legs, but was
aggravated by prolonged sitting or standing, carrying weight, impact activities, sit‐ups, and
push‐ups. The CI denied an antalgic gait and had full function of all extremities. She was
observed to have an erect posture and a “relatively normal” gait. The range‐of‐motion (ROM)
was essentially normal. Some spasm of the paravertebral muscles was noted. Provocative
testing for nerve root irritation was negative. There was no muscle atrophy. Reflexes and
strength were normal; sensation was not addressed. At the VA Compensation and Pension
examination on 7 May 2003, 6 weeks after separation, the CI reported continued LBP with
movement and tenderness, but without radiation or incontinence. The pain was aggravated by
walking for 10 minutes or sitting for five. The pain radiated to the right side of her body and
had led to 5 days of absence from work. On examination, posture and gait were normal. The
feet showed no signs of abnormal weight bearing. There was no evidence of radiation of pain
on movement, muscle spasms or tenderness. Testing for nerve root irritation was negative. All
ROM testing was slightly painful, but only slight reduced in extension and lateral flexion.
DeLuca criteria were negative. Sensation, strength and reflexes were normal. X‐rays were
normal.
The Board directs attention to its rating recommendation based on the above evidence. The
PEB and VA both rated the LBP at 10% and coded it 5295, lumbosacral strain, although the PEB
did so analogously. The Board considered the other coding options for the back, but none
offered a route to a higher rating. After due deliberation, considering all of the evidence and
mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board concluded that there was
insufficient cause to recommend a change in the PEB adjudication 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. 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 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.
2 PD12‐00546
RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of
the CI’s disability and separation determination, as follows:
VASRD CODE RATING
5299‐5295
COMBINED
10%
10%
UNFITTING CONDITION
Chronic Low Back Pain with Pain on Motion
The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20120606, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record
SFMR‐RB
XXXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review
MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD‐ZB / Mr. Brower), 2900 Crystal Drive, Suite 300, Arlington, VA 22202‐3557
SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for
XXXXXXXXXXXXXXXXXX, AR20130001374 (PD201200546)
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
XXXXXXXXX
Deputy Assistant Secretary
(Army Review Boards)
CF:
( ) DoD PDBR
( ) DVA
3 PD12‐00546
4 PD12‐00546
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