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AF | PDBR | CY2013 | PD-2013-02079
Original file (PD-2013-02079.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02079
BRANCH OF SERVICE: Army  BOARD DATE: 20140717
SEPARATION DATE: 20041103


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (63B30/Light Wheel Vehicle Mechanic) medically separated for chronic low back pain (LBP). The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The low back condition, characterized as “chronic low back pain with radiation to the right knee” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded chronic epicondylitis and testicular pain as medically acceptable. The PEB adjudicated “chronic low back pain...no focal neurological deficits” as unfitting, rated 10% citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be medically acceptable. The CI made no appeals and was medically separated.


CI CONTENTION: “My lower back condition has worsen [sic] with time. It hurts all the time and I am currently taking 10mg cyclobenazpine x2 a day. The rating for my cluster headaches is currently rated at zero, and I have headaches all the time only on my right side of the head. I take over the counter meds 400mg advil 2x a day. I had surgery on my left elbow and it hurts more now than before. I was a mechanic in the Army and I was diagnose [sic] with carpal tunnel on both hands. Left hand I had surgery and still have carpal tunnel plus loss of strength. I still having problems with my stomach and I am currently the maximum does [sic] of medications for it.”


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 chronic low back condition is addressed below. In addition, the Board will consider the not unfitting chronic epicondylitis within its purview. 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.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation. The Board likewise acknowledges the CI’s contention for rating of his chronic epicondylitis condition which was determined to be not unfitting by the PEB and emphasizes that disability compensation may only be offered for those conditions that cut short the member’s career. Should the Board judge that any contested condition was most likely incompatible with the specific duty requirements; a disability rating IAW the VASRD and based on the degree of disability evidenced at separation, will be recommended.


 RATING COMPARISON :

Service IPEB – Dated 20040716
 VA - (3 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain with Degenerative Disc Disease 5237 10% Residuals of Low Back Injury with DJD 5010-5237 10%* 20040812
Chronic Epicondylitis Not Unfitting Right Elbow Epicondylitis 5099-5024 10% 20040812
Left Elbow Epicondylitis 5099-5024 10% 20040812
Other x 1 (Not in Scope)
 Other x 13 20040812
Combined: 10%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 41215 ( most proximate to date of separation ).
*VARD 20050707 changed DC 5010-5237 to 5243 and increased rating to 20% effective 20041104 based on C&P examination 20050407.


ANALYSIS SUMMARY:

Chronic Low Back Pain with Degenerative Disc Disease Condition. The goniometric range-of-motion (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 ~8 Mo. Pre-Sep
(20040225)
 VA C&P ~3 Mo. Pre-Sep
(20040812)
 VA C&P ~ 5 Mo. Post -Sep
(200 5 0 407 )
Flexion (90 Normal) 80 ( 86,87,83 ) 90 (99) 70
Extension (30) 25 ( 27,23,26 ) 15 (15) 20
R Lat Flexion (30) 25 ( 27,25,26 ) 20 (22) 20
L Lat Flexion (30) 30 ( 27,27,29 ) 25 (26) 20
R Rotation (30) 30 ( 44,42,45 ) 30 (40) 20
L Rotation (30) 30 ( 44,47,45 ) 30 (42) 20
Combined (240) 220 220 170
Comment Painful motion
 		Active after repetition
Painful motion
No spasm
Normal gait
Normal contour 		Painful flexion from 50 to 70
Painful motion all directions
No spasm
Normal gait
 Normal contour
§4.71a Rating 10 % 10 % 10%
invalid font number 31502

Service treatment records (STRs) captures a history of chronic LBP since a lifting injury in 1996. X-rays and magnetic resonance imaging (MRI) were reported to show a bulging disc and a spondylolysis (fracture of the bony arch of the posterior vertebra). The CI continued to perform his duties to include a deployment from February 2003 to April 2003. The CI presented to the orthopedic clinic on 24 October 2003 and 5 November 2003 for exacerbation of back pain, the result of a military exercise. At the orthopedic examination, the examiner noted increased back pain and that the CI reported radiation of pain into the right leg. On further examination there was noted tenderness and the CI’s gait was normal. The back flexed to 90 degrees with pain, extended 10 degrees, and lateral flexion and rotation were characterized as “full”. Strength was normal and legs raises were negative for radicular signs. X-rays of the lumbosacral spine dated 5 November 2003 were normal. A diagnostic MRI of the lumbosacral spine dated 9 December 2003, revealed a small disc bulge at L5-S1 directed to the left without contact with nerve roots. The neural foramens were patent. There was an annular tear (tear of the outer disc layer which can be associated with pain). Follow up orthopedic evaluation concluded there was no surgical indication. A permanent physical profile was issued for back pain dated 29 December 2003, and the CI was referred for an MEB. The MEB narrative summary (NARSUM) dated 30 March 2004, noted duty limiting chronic low back pain. On examination, the CI’s gait was normal yet the CI indicated painful motion by reporting muscle spasms after returning upright from a flexed position. Strength and reflexes were normal. Also straight leg raises were negative for radicular signs.

At the time of the VA compensation and pension (C&P) examination performed on 12 August 2004, 3 months prior to separation, the CI reported he was limited to sedentary duties due to back pain. He reported the pain had recently moved from the right to the left side. The examiner noted “otherwise no evidence of radiculopathy.” On examination there was tenderness but no muscle spasm. Gait, posture and spinal contour were normal. Thoracolumbar ROM is recorded in the chart. Straight leg raise was negative for radicular signs. Strength and reflexes were normal. The CI filed a claim for increase rating with the VA on 4 January 2005. At the VA C&P examination performed on 7 April 2005, 5 months after separation, the CI reported worsened back pain with an increase of the frequency of flare up in the preceding month requiring hospitalization for 2 days in February 2005 and was scheduled for epidural injection. The examiner recorded tenderness and spasms. Gait and spinal contour were normal. Thoracolumbar ROM is recorded in the chart. The examiner opined there was additional limitation by pain after repetitive use. Leg raise was negative for radicular signs. Strength and reflexes were normal.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the chronic low back pain at 10% (coded 5237, lumbosacral strain) citing the ROM, painful motion, spasm after flexing and returning to an upright position. The VA rated the low back pain with degenerative disc disease at 10% (coded 5010-5237; traumatic arthritis-lumbosacral strain) citing the ROM and painful motion at the time of the C&P examination. The subsequent VA rating decision increased the rating to 20% citing the April 2005 examination showing pain beginning at 50 degrees of flexion. The thoracolumbar ROM at the time of the MEB examination and initial VA C&P examination supports a 10% rating for limitation of motion based on the VASRD general rating formula for diseases and injuries of the spine. The Board noted the subsequent VA rating of 20% based on pain beginning at 50 degrees of flexion at the time of the April 2005 examination. However, the April 2005 examination was contemporaneous with post-separation worsening of the condition and was not considered to have higher probative value than the prior examinations with regard to rating at separation. The MEB NARSUM examination noted muscle spasm but examinations did not show abnormal gait or spinal contour to support the next higher rating. There were no incapacitating episodes due to intervertebral disc syndrome to support a minimum rating under the alternate formula based on incapacitating episodes. Although there was a bulging disc, there was no evidence of radiculopathy or nerve involvement that warranted consideration of a separately unfitting rating for peripheral nerve impairment. 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 chronic low back pain with degenerative disc disease condition.

Chronic Epicondylitis. Review of STRs show the CI sought care in June 2003 for bilateral elbow pain of approximately 6 months duration. A physical therapy examination dated 27 June 2003, demonstrated tenderness at the bilateral elbow and discomfort with grip. Temporary duty limiting profiles were issued during June 2003 and July 2003. Although some improvement was noted the pain persisted. Orthopedic evaluation on 5 November 2003 noted tenderness but full ROM and normal strength. Injections by the orthopedic surgeon were reported to result in some improvement. X-rays of the elbows were normal (except for a small olecranon spur not correlated with the pain location). The December 2003 profile listed only back pain as limiting. The MEB history and physical examination (DD Form 2808) dated 10 February 2004, made no reference to epicondylitis nor did the DD Form 2807-1 completed by the CI on 14 January 2004. A rheumatology evaluation performed on 16 March 2004 recorded a history of pain in multiple joints after anthrax vaccination with persistent elbow pain. Examination recorded bilateral elbow tenderness without swelling and that elbows ROM were “full.” The rheumatologist concluded there was no inflammatory joint process and thought the bilateral epicondylitis was likely occupational in nature.

The MEB NARSUM examination dated 30 March 2004, recorded onset of elbow pain while deployed to Turkey from February to April 2003. The examiner noted the pain as “recurrent nature” but stated it had been “treated conservatively with success.” On examination, the elbows had full ROM. There was mild discomfort with palpation and “some” discomfort with resisted finger extension consistent with bilateral epicondylitis. The commander’s statement dated 27 May 2004, reported work limitations due the back and elbows. The commander statement goes on to say“…duty capabilities are also being compromised by severe pain in his elbows that is aggravated when he lifts equipment or attempts to crawl under vehicles.” Chronic epicondylitis was referred to the PEB as medically acceptable and was adjudicated as not unfitting by the PEB.

At the VA C&P examination in August 2004, 3 months prior to separation, the CI reported bilateral elbow pain causing decreased grip strength that was aggravated by activity requiring use of hands. On examination, the CI reported moderate tenderness of the bilateral elbows. ROM was normal (flexion to 140, full extension after repetition) and strength was normal. The examiner noted that other tests for bilateral epicondylitis were “questionably negative.” The examiner commented “the Veteran states that the effect on his ability to function is significant. Although the Veteran stated that his grip strength in the right hand was decreasing no such decrease was noted during the physical examination. The diagnosis seems well established, however the functional impairment is difficult to assess.” The Board noted the commander’s statement reporting work limitations due to the elbows condition. However, the condition was not profiled at the time of DES entry and was not the cause for referral to the MEB. The Board also noted the CI did not mention the elbow pain condition at the time of the MEB examination. Therefore, absent the back pain, the elbow pain condition would not have caused the CI to be referred into the DES.

The Board noted that the mere presence of this common musculoskeletal condition is not disqualifying for military service and afflicted individuals may experience chronic recurring symptoms over a prolonged period of time but are generally able to function. Medical evaluation of the CI did not disclose an underlying inflammatory process and the condition was considered occupational in nature. Clinical examinations were normal except for tenderness and subjective report of pain consistent with a mild condition. The MEB NARSUM examiner noted some improvement with treatment although there was some return of symptoms. The Board concluded that there was not a preponderance of evidence prior to separation that persuaded the Board the painful elbow condition was separately unfitting. 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 chronic epicondylitis conditions and so no additional disability ratings are recommended.


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 low back pain with degenerative disc disease condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended chronic epicondylitis condition, the Board unanimously recommends no change from the PEB determination as not unfitting. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131008, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




                           XXXXXXXXXXXXXXXXX
                           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 XXXXXXXXXXXXXXXXX, AR20150002517 (PD201302079)
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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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