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AF | PDBR | CY2013 | PD-2013-02039

Original file (PD-2013-02039.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX CASE: PD-2013-02039
BRANCH OF SERVICE: Army BOARD DATE: 20150304

SEPARATION DATE: 20050513

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Automated Logistics Specialist) medically separated for lower back pain. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) but was authorized to perform an alternate physical fitness test. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “chronic low back pain secondary to degenerative disc disease” 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 low back pain with L5/S1 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: “Was only rated for one condition.”

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 20050303	VA* - (~1 Mos. Pre-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Chronic Low Back Pain with L5/S1 Degenerative Disc Disease	5237	10%	Lumbar Spine Degenerative Disc Disease L5-S1	5010-5242	10%	20050401
Other x 0	Other x 23
RATING: 10%	RATING: 60%

* Derived from VA Rating Decision (VA RD ) dated 200 50609 (most proximate to date of separation [ DOS ] ) .

ANALYSIS SUMMARY:

Low Back Pain. The earliest report of lower back pain in the service treatment record was dated 22 July 2003 at which time the CI had pain for a week. Five weeks later she again had lower back pain that was treated with heat and nonsteroidal anti-inflammatory and muscle relaxant medication. Chiropractic treatments were performed in March and April 2004. Intermittent radiculopathy to the right leg/knee was noted in April 2004; and medication was continued. X-rays of the lumbar spine showed L5-S1 degenerative disc disease (DDD) in May 2004. Because of pain radiating down the right buttock and thigh, a magnetic resonance imaging was performed on 18 October 2004 that confirmed the L5-S1 DDD with a small central disc protrusion and moderate foraminal (nerve outlet openings) narrowing secondary to arthric changes (facet arthrosis). Having failed conservative treatment and the need for continued pain medication (Ultram), a MEB was initiated in November 2004. In December 2004, an evaluation noted chronic low back pain with occasional radicular symptoms, but no weakness, numbness or bowel/bladder dysfunction. There was a full range-of-motion (ROM) with negative straight leg raise tests (to determine nerve root irritation) and an unremarkable neurologic examination. Trigger point injections (TPI) of the right paralumbar muscles was carried out. After an acupuncture session in December 2004, the CI developed severe pain in the lower back with numbness and tingling that was treated intramuscular pain medication (Toradol) and Valium (diazepam) for muscle spasm. Additional treatments of TPI contined monthly from January through March 2005; however, pain severity of 6-7/10 (10 being the worst pain) persisted. In September 2005, a pain management consultant noted the CI had normal spinal curves, a full lumbar ROM, tenderness in the lumbar paraspinal muscles and over her sacroiliac joints, negative straight leg raising, a normal gait, and the ability to perform a single leg stance and toe and heel walk without difficulty. Lumbar spinal injections under fluoroscopic guidance were scheduled along with a core stabilization therapy program, pain psychology, and avoidance of narcotics. Ultram and a muscle relaxant (Flexeril) were continued. Several weeks of good pain control were achieved after the spinal injections. Back pain with minimal radicular symptoms followed the second injection series; and physical therapy was continued. Percocet, a narcotic, was resumed along with the Ultram and muscle relaxant medication. Bilateral sacroiliac injections were given in April 2006 and Lidoderm patches (a topical anesthetic pain reliever) were added to her medication protocol in May 2006 at which time she had a full flexion, slightly limited extension, abnormal gait, and negative leg raise with no motor or sensory defects.

A permanent L3 profile was issued on 16 December 2004 with limitations of military functional activities including ruck marching and physical fitness. The commander’s statement dated 16 December 2004 indicated that based on her profile she was unable to perform duties as required by her grade and MOS based on her profile, but had not missed any days of duty since July 2004 when he became the commander. However, he noted her daily performance had been exceptional and her profile did not impact select missions. At the MEB examination dated 3 January 2005, the CI reported “back problems since 1998, various treatments and meds, injury 1997 or 98” and “Numbness, tingling – some of both since 1998 due to lower back injury.” The MEB physical examination dated 3 January 2005 noted mild tenderness to palpation diffusely from L4 through the S1 area. There was a negative straight leg raise test (to determine nerve root irritation) and negative sciatic notch (where the piriformis muscle and nerves pass) tenderness. The CI was able to heel, toe and duck walk without problems, had 2+ deep tendon reflexes, and a normal gait. The MEB NARSUM dated 11 January 2005 noted the CI had no prior back pain until late 1997 or early 1998 when she was pulling tires off a 5-ton truck as a Light Wheeled Vehicle Mechanic and wrenched her back and “had problems ever since.” In 2002, two ruck marches made her back worse and running increased the symptoms. Examination of the spine was based on the MEB examination as noted above.

At the VA Compensation and Pension examination dated 1 April 2005, performed a month prior to separation, the CI reported lower back pain for 8 years described as aching with a severity of 8/10 and six incidents of incapacitation for a total of 12 days in the year prior to the examination and resulted in two times lost from work per month. There were no complaints of radiating pain on movement, muscle spasm was absent, and there was no tenderness. Straight leg raise was negative bilaterally. There was no ankylosis of the spine and the ROM measurements were: f lexion 90 degrees , e xtension 30 degrees , r ight l ateral flexion 30 degrees , l eft l ateral flexion 30 degrees , r ight rotation 30 degrees , and left rotation 30 degrees . J oint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Th e re were no signs of an interverteb r al disc syndrome with chronic and permanent nerve root involvement.

The 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)	PT ~4 Mo. Pre-Sep (20050105) p.211	MEB ~3 Mo. Pre-Sep (20050210) p.44	VA C&P ~1 Mo. Pre-Sep
Flexion (90 Normal)	80(75,78,80)	-	90
Extension (30)	15(15,16,16)	-	30
R Lat Flexion (30)	20(15,18,18)	-	30
L Lat Flexion (30)	20(22,22,22)	-	30
R Rotation (30)	30(30,30,30)	-	30
L Rotation (30)	30(30,30,30)	-	30
Combined (240)	195	-	240
Comment	Pain with active movem ents ; increase muscle guarding	Negative straight leg raise; negative sciatic notch tenderness	Degenerative disc disease; DeLuca negative
§4.71a Rating	10%	-	VA 10%

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating using code 5237 (lumbosacral strain) for chronic low back pain with L5/S1 DDD without focal neurological deficits and ROM was limited by pain and muscle guarding. The VA assigned a rating of 10% using code 5010-5242 (d egenerative arthritis) for DDD at L 5-S1. The Board must establish a functional impairment linked to fitness in order to recommend a separate rating for a radiculopathy associated with unfitting spine conditions; a threshold clearly not reached by the evidence in this case especially after pain management treatments. The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a , which states that “rating is performed w ith 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.” The Board sought a route for a higher rating , but was unable to find one; however, the Board noted that the CI had 12 days of incapacitation warranting a 10% rating, which is congruent with the PEB and VA ratings and had guarding, but without any gait disturbance, thereby not meeting a 20% rating. Therefore, no additional or higher rating can be assigned. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the lower 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 lower 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 20131026, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
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, AR20150011179 (PD201302039)

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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AF | PDBR | CY2013 | PD-2013-02039

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