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AF | PDBR | CY2013 | PD-2013-01800
Original file (PD-2013-01800.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX        CASE: PD-2013-01800
BRANCH OF SERVICE: Army         BOARD DATE: 20140506
SEPARATION DATE: 20050319


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (63B/Light Wheeled Mechanic) medically separated for a back condition. The CI injured his back in 2002 when he was dropped by a soldier who was doing a buddy carry. The back condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). 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 Informal PEB adjudicated “chronic back pain, w/o neurologic abnormality” as unfitting, rated 20% with application of the 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 back condition is addressed below; 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 Board for Correction of Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20050120
 VA - (2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Back Pain, w/o Neurologic Abnormality 5299-5237 20% Degenerative Changes of the Lumbar Spine 5242 10% 20050502
Other x 0 (Not in Scope)
 Other x 0 20050502
Combined: 20%
 Combined: 10%
Derived from VA Rating Decision (VA RD ) dated 200 50624 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:
Chronic Back Pain. The service treatment records indicate a history of chronic low back pain (LBP) starting in September 2002 . The CI reported that his back pain began after being dropped by another soldier during a buddy carry exercise . Serial diagnostic imaging studies showed no significant pathology . A 30 October 2003 lumbar spine X-ray showed mild spurring without significant disk space narrowing or spondilolisthesis (forward displacement of a vertebra over a lower segment) . Mild lumbar spondylosis (degenerative changes) with loss of lordosis ( loss of normal lumbar spine curvature ) was noted suggesting spasm . A 2 December 2003 lumbar spine magnetic resonance imaging study showed no evidence of abnormality in the vertebral bodies or disk material . No evidence of disk herniation, significant disk bu lge or degenerative changes were identified. Treatment included medication therapy (pain, muscle relaxants), physical therapy and trigger point injections . The 8 April 2004 physical profile (PULHES 113111) permitted the CI to walk, bike, or swim at his own pace and distance . The profile prohibited the CI from marching, prolonged standing, lifting or carrying more than 20 pounds of weight, Army Physical Fitness Test ( APFT ) or alternate APFT . At the time of the MEB history of physical examination on 13 September 2004, the examiner recorded a normal gait, intact reflexes, normal strength and “no difficulty with clothes” (apparently indicating no difficulty disrobing and dressing for the examination). At the 5 November 2004 MEB n arrative s ummary ( NARSUM ) examination, the CI complained of constant 4/10 lower back pain which increased to 8-9/10 pain with prolonged standing, bending, or lifting . The CI reported he was able to walk slowly , at his own pace, for approximately 1-1/2 miles . He also complained of pain with running with occasional muscle spasms and radicular symptoms (pain shooting down back of leg and numbness) . On examination , the patient was tender to palpation on the lumbar para-spinal muscles. The range - of - motion (ROM) examination is recorded in the chart below . The 2   May 2005 VA C ompensation and P ension (C&P) examination, 2 months after separation, noted that the pain in the low back did not radiate and did not affect his ability to walk. The CI reported that even taking the wrong steps could cause a flare up of pain lasting one to two days ; however , the examiner recorded that there were no episodes of intervertebral disk syndrome in the preceding 12 months. The CI reported difficulty with lifting heavy objects and bending over. On examination, there was pain at the limits of range with the measured ROM recorded in the chart. The ROM was not additionally limited by pain, fatigue, weakness or lack of endurance . The straight leg test was negative for radicular signs and there was no evidence of motor weakness, asymmetric deep tendon reflexes, abnormal sensory findings or abnormal gait . The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)		 MEB ~5 Mo. Pre-Sep
(20041105)		 VA C&P ~2 Mo. Post-Sep
(20050502)
Flexion (90 Normal) 60 75
Extension (30) 20 30 (35)
R Lat Flexion (30) 20 25
L Lat Flexion (30) 20 25
R Rotation (30) 30 (35) 30
L Rotation (30) 30 (35) 30
Combined (240) 180 215
Comment
Tenderness		 Painful motion
No reduction with repetition
Gait normal
§4.71a Rating 20% 10%
invalid font number 31502
The B oard directs attention to its rating recommendation based on the above evidence . The PEB rated the unfitting back condition at 20% citing ROM from the MEB NARSUM examination . The VA rated the back condition at 10% citing ROM from the VA C&P examination . The limitations of ROM at the time of the MEB NARSUM examination supported 20% based upon the general rating formula for diseases and injuries of the spine (forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees) . The limitations of ROM at the time of the VA C&P examination supported 10% based upon (forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees) . The Board found no evidence to support a higher rating based on limitations of ROM . A lthough occasional radiating pain was reported, no evidence existed to support nerve root impingement or radiculopathy for consideration of a separately unfitting 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 c hronic b ack p ain without n eurologic a bnormality.


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. In the matter of the chronic back pain without neurologic abnormality 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 re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131024, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                                   
XXXXXXXXXXXXXXXXXX
President
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, AR20150000996 (PD201301800)

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                                                  XXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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