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AF | PDBR | CY2013 | PD-2013-01871
Original file (PD-2013-01871.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-01871
BRANCH OF SERVICE: Army  BOARD DATE: 20150403
SEPARATION DATE: 20050226


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Army Reserve E-4 (Motor Transport Operator) medically separated for a back condition. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). “Degenerative disk disease of the lumbosacral spine, L5 through S1”was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated “chronic back pain due to degenerative disc disease…” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “The rating was unfit due to the severity of the injury. To this day, it is affecting my everyday living. I also had a secondary injury to to the injury of my back and was not attended to, due to only being able to list my chief complaint which was my back at the time due to the pain inabilities.”


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 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.


 RATING COMPARISON :

IPEB – Dated 20050128
 VA* - (~12 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Back Pain Due to DDD without Neurologic Abnormality... 5299-5242 10% Lumbosacral Strain 5237 10% 20060213
Other x 0
Other x 6
RATING: 10%
 RATING: 20%
* Derived from VA Rating Decision (VA RD ) dated 200 60517 (most proximate to date of separation [ DOS ] )


ANALYSIS SUMMARY:

Chronic Back Pain Due to Degenerative Disc Disease . While deployed, the CI slipped on some stairs while wearing all her gear. The next morning on 26 May 2004, she awoke with significant back pain and spasm limiting her range-of-motion (ROM). She was managed conservatively with medications and duty limitations and her pain resolved. On 15 September 2004, she again strained her back and was again managed conservatively. Spasm and reduced ROM were present as well at this encounter. She did well until she reinjured her back in physical training on 10 October 2004. She was seen in physical therapy (PT) on 29 October 2004 and noted to have full, painless ROM. Her symptoms did not resolve after treatment and she was referred for a neurosurgical evaluation and seen on 2 November 2004. A magnetic resonance imaging showed a small central herniation at L5S1 with degenerative disc disease and she was re-deployed on 3 November 2004 to her home station. When seen in primary care on 15 November 2004, she was noted to have left para-lumbar tenderness, but good ROM. At an orthopedic appointment on 21 December 2004, the ROM of the back was normal as was the neurological examination, gait and stance. Spasm was absent. The CI was issued a L3 profile and referred for MEB. On 10 January 2005, approximately 2 months prior to separation, ROM measurements were taken in PT and showed a significant reduction in flexion of 20 degrees limited by pain (normal 90 degrees). There was an increase in lordosis curvature; however, no guarding or tenderness to palpation. Spasm was not recorded. Formal ROM measurements during a PT examination 2 days later were identical, but annotated as lumbar flexion vice thoracolumbar flexion, reducing its probative value. There was no sign of radiculopathy or spasm. Lumbar lordosis was slightly increased. Left paraspinal tenderness was present. The narrative summary was dated 13 January 2005 was also approximately 2 months prior to separation. It noted ongoing low back pain (LBP) refractory to conservative treatment. On examination she was in no distress and had a gait free of pain (normal). The ROM values were from PT the day prior. The neurological examination was normal. Heel and toe walk were normal. The limitation in flexion of 20 degrees is not consistent with a normal gait.

At the initial, general VA Compensation and Pension (C&P) examination performed on 5 May 2005, just over 2 months after separation, the CI reported chronic LBP with radiation down both legs, left worse than the right. She subjectively noted numbness and weakness in both lower extremities. On examination, she had obvious back pain with movement, but normal gait, station, and neurological examination. The ROM was not documented. A VA primary care visit to establish care on 17 November 2005, 9 months after separation, noted that she walked for exercise. The examiner noted that her flexion was quite limited and that she “goes approximately 45 degrees before complaining of pain. She is able to get herself from the exam table without assistance.” No comment was made on the actual limit in flexion, just the onset of pain.

A second VA C&P examination was performed just less than 12 months after separation on 13 February 2006. The CI stated that she had missed 2 days of school the past 12 months. Her gait and posture were normal. The ROM was slightly limited in flexion, extension, and left lateral flexion ten degrees each for a total ROM of 210 degrees. Spasm was not documented. The neurological examination was normal. A VA primary care noted dated 11 April 2006, almost 14 months after separation, noted that she continued to have LBP and had traction the prior hour in physical therapy. Her flexion was limited to “about 50 degrees.”

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition at 10% using an analogous code 5299-5242 (degenerative arthritis of the spine). The VA also rated the back at 10% and used the code 5237 (lumbosacral strain). The Board considered the evidence. Although the MEB ROM values support a 40% rating at face value, these are reduced in probative value due to the probability that they represent only lumbar motion rather than thoracolumbar motion. In addition, these are not consistent with the pathology in evidence and limited by subjective pain; and, there are other examinations which ranged from at least 45 degrees to normal. She was also noted to be in no distress and to have a normal gait. The VA C&P examination dated 13 February 2006 is within the 1-year period after separation and is also consistent with the pathology present on examination and pre-MEB ROM measurements where she showed normal to slight limitations. It is therefore assigned a higher probative value IAW VASRD §4.7. The Board also noted that multiple normal neurological evaluations are in evidence and that the presence of an unfitting radiculopathy at separation is not supported. 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 fitness determination for the back 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 back pain 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 20131023, w/atchs
Exhibit 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, AR20150011062 (PD201301871)


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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