Upgrade.Vet

AF | PDBR | CY2013 | PD-2013-01522

Original file (PD-2013-01522.rtf) Auto-classification: Approved

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX CASE: PD -20 1 3 - 0 1522
BRANCH OF SERVICE: Army BOARD DATE: 201 5 0121

Separation Date: 20040820

SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Petroleum Supply Specialist) medically separated for chronic subjective thoracolumbar pain, without neurologic abnormality, and sensorineural hearing loss condition. The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L3/H3 profile and referred for a Medical Evaluation Board (MEB). The chronic subjective pain, without neurologic abnormality, with thoracolumbar condition and Sensorineural hearing loss, characterized as “chronic mid-back pain with scoliosis” and “bilateral moderate neural hearing loss” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic subjective pain, without neurologic abnormality, with thoracolumbar” as unfitting rated at 10% IAW AR 635-40 para B29e and “Sensorineural hearing loss” as unfitting, and rated at 0%. The CI made no appeals and was medically separated.

CI CONTENTION : “I was diagnosed with one condition. I had several separate conditions that contribute to the chronic back pain.”[sic]

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

invalid font number 31502

RATING COMPARISON :

Service IPEB – Dated 20040226	VA - based on Service Treatment Records (STR)
Condition	Code	Rating	Condition	Code	Rating	Exam
Chronic Subjective Thoracolumbar Pain, without Neurologic Abnormality	5299-5237	10%	Scoliosis, Thoracolumbar Spine, with Chronic Back Pain	5299-5237	10%*	STR
Sensorineural Hearing Loss	6100	0%	Bilateral Hearing Loss	6100	Non Service Connected	STR
Other x0	Other x1	STR
Combined: 10%	Combined: 10%

Derived from VA Rating Decision (VARD) dated 20050921 (most proximate to date of separation [DOS])
invalid font number 31502

ANALYSIS SUMMARY :

Chronic Subjective Pain, without Neurologic Abnormality, with Thoracolumbar Condition . The CI developed low back pain ( LBP ) in November 2002 from lifting heavy hoses, gates and pumps while preparing for deployment. She was seen in the emergency room with physical exam findings of bilateral tenderness in the lumbar muscles. The CI continued with mechanical LBP and was referred to n eurosurgery in June 2003. The n eurosurgeon noted physical exam findings of left p ar aspinal region with moderate tenderness to palpation (TTP) and paraspinal spasm. The p hysical t herapist (PT) documented TTP in the mid thoracolumbar region and left paraspinal muscles. A lumbar spine X -ray demonstrated lumbar scoliosis. The c hiropractor noted that the CI reported sharp pain from the thoracolumbar junction that radiated down the right lower extremity which was worsening. The physical exam findings were positive for thora columbar pain with normal motor and sensory testing. A repeat thoracolumbar X -ray continued to show thoracolumbar scoliosis. The o rthopedist documented that the CI wanted to stay in the Army, but could not do her job and wanted to change her MOS. The physical exam findings were slight TTP in the thoracic spine and lower lumbar spine and forward flex limited to mid - tibia and there were normal motor, sensory and reflex exams. The c ommander’s s tatement indicated he felt that the CI could continue to make a great contribution to the Army and she could perform and meet the standards in another MOS and he recommended reclassification.

The PT range - of - motion (ROM) exam for the PEB with physical exam findings of flexion 80 degrees (normal 90 degrees ), extension 10 degrees (normal 30 degrees) limited due to pain, right lateral flexion 16 degrees (30 degrees normal), left lateral flexion 16 degrees (30 degrees normal) limited due to pain; right rotation 17 degrees (30 degrees normal), and left rotation 20 degrees (30 degrees normal). The PT documented that “the scoliosis was not noted on the CI’s entrance physical” and no diagnosis was made prior to service .

The MEB n arrative summary exam approximately 7 months prior to separation documented back pain several times per week, made worse with walking, standing bending or lifting. The CI described the pain as a tight aching back pain with muscle spasms and increased pain which would worsen a s the day progressed. The physical exam findings were scoliosis, negative straight leg raise and negative Waddell signs. The spine ROM’s were reported in centimeters and a tape measure was used instead of a goniometer. The examiner rated the pain according to the American Medical Association pain scale at moderate and occasional . The c hiropractor documented chronic LBP with pain that radiated down the left lower extremity with physical exam findings of decreased sensation at the L4-S1 levels, positive straight leg raise and TTP with muscle spasm at the L5 level and a shortening of the left lower extremity. A repeat thoracic spine X -ray continued to demonstrate a convex right lower thoracic scoliosis. A repeat lumbar spine X -ray was unchanged from prior X -rays and continued to show a left convex lumbar scoliosis.
A lumbar spine magnetic resonance imaging ( MRI ) demonstrated a L5-S1 right - sided broad disc protrusion with impingement on descending right S1 nerve root and on thecal sac; and moderate foraminal s tenosis at L4-5 . The CI was seen by n eurology in 2007 and a repeat lumbar spine MRI was unchanged. The VA Compensation and Pension exam was not available; however, the VARD on 21 September 2005 used the ROM’s from the PT exam on 24 February 2004.

The Board direct ed attention to its rating recommendation based on the above evidence. The PEB coded the chronic subjective pain, without neurologic abnormality, with thoracolumbar condition as 5299 analogous to 5237 (lumbosacral or cervical strain), rated at 10%. The VA coded the scoliosis thoracolumbar spine, with chronic back pain (claimed as back condition) used the same coding as the PEB and also rated it 10% based on STR evidence. The “General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease . ” There was well-documented evidence on spine X -rays and physical exams that the CI had scoliosis and that this condition did not exist prior to service . The CI met the 20% rating criteria for “ muscle spasm, guarding, or localized tenderness resulting in abnormal gait or abnormal spinal contour . ” The Board found no separately unfitting neurological condition as related to the spine disability. 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 c hronic s ubjective p ain, without n eurologic a bnormality, with t horacolumbar condition.

Sensorineural Hearing Loss Condition. The CI developed hearing loss during Basic Training and was evaluated by Audiology and Ear Nose and Throat (ENT). During the CI’s deployment to Kuwait she was exposed to a lot of loud sounds and she reported worsening of her hearing loss. The Audiologist in January 2002 and February 2002 reported worsening of the hearing loss as evidenced by each audiogram. The ENT documented no ear trauma and diagnosed bilateral symptomatic moderate sensorineural hearing loss. The CI was given hearing aids. The CI was given a permanent H3 profile for sensorineural hearing loss, both ears with specific restrictions noted on the profile. The MEB audiology examination approximately 7 months prior to separation showed that the CI’s left ear average loss was 35.0 dB at the pure tone thresholds of 1000-4000 Hertz with 100% speech discrimination; and the right ear average loss was 33.75 dB (all less than 55 dB) at the pure tone thresholds of 1000-4000 Hertz with 100% speech discrimination. The commander’s statement indicated that he felt that the CI could continue to make a great contribution to the Army and she could perform and meet the standards in another MOS and he recommended reclassification.

The Board direct ed attention to its rating recommendation based on the above evidence. The PEB coded the s ensorineural h earing l oss condition as 6100 , rated at 0%. The VA used the same coding and rated as not service-connected based on the evidence in the STR. The MEB audiology examination approximately 7 months prior to separation showed that the CI’s left ear average loss was 35.0 dB at the pure tone thresholds of 1000-4000 Hertz with 100% speech discrimination; and the right ear average loss was 33.75 dB (all less than 55 dB) at the pure tone thresholds of 1000-4000 Hertz with 100% speech discrimination. Application of VASRD §4.86a and §4.85 yields a 0% rating. The CI had no history of tinnitus, phonophobia , vertigo or other evidence to support Meniere’s syndrome (endolymphatic hydrops) which if present would yield a higher rating. 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 s ensorineural h earing l oss 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. As discussed above, PEB reliance on AR 635-40 for rating the c hronic s ubjective p ain, without n eurologic a bnormality, with thoracolumbar condition was operant in this case and the condition was adjudicated independently of that regulation by the Board. In the matter of the c hronic s ubjective p ain, without n eurologic a bnormality, with t horacolumbar condition, the Board unanimously recommends a disability rating of 20 %, coded 5299-5237 IAW VASRD §4.71a. In the matter of the s ensorineural h earing l oss condition and IAW VASRD §4. 85-6 , the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s sc ope of review for consideration .

RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING
Chronic Subjective Pain, without Neurologic Abnormality, with Thoracolumbar	5299-5237	2 0%
Sensorineural Hearing Loss	6100	0%
COMBINED	2 0%

invalid font number 31502

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20 130917 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President

DoD Physical Disability Board of Review

SAMR-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 XXXXXXXXXXXXXXX , AR20150009858 (PD201301522)

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                                                  XXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

Similar Decisions

AF | PDBR | CY2013 | PD 2013 01035

Original file (PD 2013 01035.rtf) Auto-classification: Denied

The hearing and back conditions, characterized as “hearing loss” and “back pain w/T8–T9 and L4-L5 disc degeneration disease,” were the only two conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The CI was then medically separated. Both the VA and the PEB rated the condition at 10%.
AF | PDBR | CY2013 | PD 2013 00582

Original file (PD 2013 00582.rtf) Auto-classification: Denied

A new MEB was done and identified and forwarded generalized anxiety disorder and alcoholdependence as medically acceptable.The Informal PEBadjudicated chronic bilateral knee pain, chronic back pain, due to DDD, without neurologic abnormality and sensorineural hearing loss as unfitting, rated 10%, 10%, and 0%respectively, citing the US Army Physical Disability Agency (USAPDA) pain policyand the VA Schedule for Rating Disabilities (VASRD).The remaining conditions were determined to be not...
AF | PDBR | CY2013 | PD-2013-02665

Original file (PD-2013-02665.rtf) Auto-classification: Denied

The PEB adjudicated “chronic low back pain (LBP) without neurologic abnormality” as unfitting, rated 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. RECOMMENDATION : The Board,...
AF | PDBR | CY2011 | PD2011-00427

Original file (PD2011-00427.docx) Auto-classification: Denied

Chronic back pain and scoliosis were forwarded to the Physical Evaluation Board (PEB) as separate medically unacceptable conditions IAW AR 40-501. The PEB adjudicated chronic back pain as unfitting, rated 10%, citing criteria from the Veterans Administration Schedule for Rating Disabilities (VASRD). The Board readily agreed that the 5293 code (intervertebral disc syndrome) was not applicable in this case since no data in evidence suggested that the CI suffered incapacitating episodes per...
AF | PDBR | CY2013 | PD-2013-01800

Original file (PD-2013-01800.rtf) Auto-classification: Denied

SEPARATION DATE: 20050319 The back condition, characterized as “chronic low back pain”was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The range-of-motion (ROM) examination is recorded in the chart below.
AF | PDBR | CY2011 | PD 2011 00366

Original file (PD 2011 00366.rtf) Auto-classification: Denied

Service IPEB – Dated 20031201VA - (2 Mos. The CI continued his post-operative care with both orthopedics and physical therapy for LBP.The commander’s statement indicated that the CI was able to perform duties in-garrison as a unit mail clerk;however he was not deployabledueto his inabilityto perform his MOS duties as an Infantryman.The MEB narrative summary (NARSUM) examination(obtained approximately 8 monthsprior to separation),contains documentation that the CI had marked and frequent LBP...
AF | PDBR | CY2014 | PD-2014-02599

Original file (PD-2014-02599.rtf) Auto-classification: Denied

The VA rated it at 10%, coded 5237 (lumbosacral strain).The Board agreed that the evidence in record supported the 10% rating according to the current Veterans Affairs Schedule for Rating Disabilities (VASRD)general formula for rating the spine based upon combined TL ROM of greater than 120 degrees but not greater than 235 degrees. Bilateral knee conditions . In the matter of the chronic LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB...
AF | PDBR | CY2013 | PD2013 00255

Original file (PD2013 00255.rtf) Auto-classification: Denied

A post-deployment examination noted only complaint of hearing loss. No specific injury was indicated.The CI reported he was unable to perform his duties as a mortar soldier due to back pain. The determination was continued at the time of the 5 September 2008 rating decision.The PEB rated the back condition 10%, coded 5237 (lumbosacral strain) for motion limited by pain (with likely application of service regulations) noting the absence of traumatic injury and normal X-rays.The limitation...
AF | PDBR | CY2014 | PD-2014-00457

Original file (PD-2014-00457.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 the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The shoulder was reviewed and considered by the Board. RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.
AF | PDBR | CY2009 | PD2009-00071

Original file (PD2009-00071.docx) Auto-classification: Denied

ROMs were pain limited to Cervical: 30˚/190˚, and Thoracolumbar 30˚/140˚. Although Physical Evaluation Board findings showed that your chronic cervical and thoracic pain was secondary to myofascial pain syndrome, VA finding showed instability of the cervical spine with limited range of motion, and chronic sprain, with scoliosis thoracolumbar spine, with limited range of motion which warrant the higher evaluation. The Cervical spine condition rating of 5021-5237 at 20% for forward flexion...

Search Decisions

Decision Text

AF | PDBR | CY2013 | PD-2013-01522

Similar Decisions