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AF | PDBR | CY2013 | PD-2013-02204
Original file (PD-2013-02204.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:XXXXXXXXXXXXXXXXXXXXXX      CASE: PD-2013-02204
BRANCH OF SERVICE: Army  BOARD DATE: 20150324
SEPARATION DATE: 20061012


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Respiratory Specialist) medically separated for low back pain (LBP). The back condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS); however, his physical profile authorized him to perform an alternate aerobic event to satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). “Chronic non-radicular pain in cervical, thoracic and lumbar spine,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded three other conditions (abnormal stool pattern, gastric polyp and pes planus) for PEB adjudication. The Informal PEB (IPEB) adjudicated chronic radiating LBP as unfitting, rated 0%, with likely application AR 635-40 for pain limited motion. The remaining conditions were determined to be not unfitting . The CI requested a reconsideration of the PEB findings; however, the PEB adhered to the original finding and recommendations; he subsequently withdrew his request for a Formal PEB and was medically separated.


CI CONTENTION: “I would like a review of my disability rating for degenerative disc disease. Over the last several years, my condition declined and limited my career options. I require breaks and changes in my position from sitting to standing and vice versa to prevent muscle spasms and pain. Thank you for your consideration.”


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.


RATING COMPARISON :

IPEB – Dated 20060711
 VA* - (~2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Radiating Low Back Pain 5299-5237 0% Degenerative Arthritis Cervical, Thoracic and Lumbosacral Spine 5237 10% 20061127
Neck Pain Not Unfitting
Other x 3 (Not In Scope)
 Other x 0
RATING: 0%
 RATING: 10%
* Derived from VA Rating Decision (VA RD ) dated 20 061215 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY:

Chronic Radiating Low Back Pain. A note dated 8 February 2006 for follow-up of lower back pain indicated the CI received brief relief with hot tubs, but no overall improvement and no relief with his first sacroiliac (SI) injection a week earlier. Examination revealed pain in the SI joints of the lower back. An orthopedic evaluation was performed on 10 March 2006 and noted the CI had LBP for 4 years. The CI had intermittent shooting sharp pain down the gluteal muscles (of the buttocks) bilaterally and intermittent paresthesias on the left greater than the right. He had chronic diarrhea, but no bladder dysfunction. Nonsteroidal ant-inflammatory medication, narcotics, and steroids failed to provide relief. Examination revealed pain with lumbar extension. There was no paraspinous tenderness and there was full range-of-motion (ROM) of both lower extremities. The orthopedic impression was non-specific global spine pain with L4-L5 and L5-S1 degenerative disc disease. A rheumatology consultation, chiropractic treatment, and physical therapy (PT) were recommended. On 22 March 2006, the CI was noted to have had pain relief with Neurontin (for nerve pain) over the prior month. The CI deferred a discogram (to define the disc-spine relationship); and no surgery was planned. Later that evening the CI had an emergency room visit for the complaints of palpitations, shortness of breath, left arm pain and 2 weeks of tingling of the legs; however, no clinical details were available for review.

The MEB narrative summary (NARSUM) dated 22 March 2006 noted the CI had back pain since the summer of 2002 that developed from heavy lifting as part of his duties as a mechanic. Initially the pain was triggered by excessive activity; however, over time it increased in frequency and intensity. He transitioned his MOS to Respiratory Therapist, which involved prolonged sitting and standing that evoked pain. A magnetic resonance imaging (MRI) showed an L4-5 loss of disc height and a broad base disk bulge without nerve displacement or impingement and a L5-S1 midline disk bulge without nerve impingement. The LBP did not respond to treatment with medication, PT, or spinal injections and was constant with a severity of 6/10 (10 being the worst) up to 8/10 with activity. He had a non-antalgic gait with normal, but slow, lumbar flexion, painful extension and negative bilateral straight leg raise testing (to determine nerve root irritation). A permanent L3 profile was issued on 31 March 2006 for LBP with limitations of functional military activities and physical fitness testing as well as no running, jumping, ruck marching, standing more than 30 minutes at a time, or lifting more than 25 pounds. The commander’s statement dated 14 April 2006 indicated the CI complained of low back pain prior to deployment, but it had not affected his job performance. The CI voluntarily reclassified from a light wheeled vehicle mechanic to respiratory specialist. However, because of the back pain, he worked in non-critical wards and was unable to move patients or ventilators, lift or carry some oxygen tanks, or provide chest physiotherapy. At the MEB physical examination dated 8 May 2006, the examiner recorded the CI’s history of cervical, thoracic, and lumbar pain since 2002 with tingling and numbness of both legs and feet intermittently and noted no tenderness of the spine and LBP with motion at the waist.

At t he VA Compensation and Pension exam ination dated 27 November 2006, performed approximately 2 months after separation, the CI reported he suffered from aching, oppressing, burning, sharp pains in his back since 2002 , but did not recollect any specific injury , and noted the LBP was constant and was 7/10 in severity and had always been associated with stiffness. Multiple specialists were consulted , but treatments, injections and medication were ineffective or gave no significant relief of the LBP , which was made worse by physical activity, prolonged sitting, standing and/or heavy lifting . As a result, the CI was unable to run or participate in activities that require d repetitive bending and/or reaching overhead. Two separate occasions of incapacitation were authorized with bed confinement of 2 days each. The examiner noted the CI had a normal posture and gait and did not use any supportive devices. Examination of the thoracolumbar spine revealed it was symmetrical without any abnormal curvatures in appearance and with no radiation of pain on movement, no muscle spasm, no tenderness , and no evidence of ankylosis . Bilateral straight leg raising tests were negative. The thoracolumbar ROM for flexion was 70 degrees ( n ormal 90 degrees) and the combined ROM was 205 degrees ( n ormal 240 degrees). The ROM was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination. T here was no evidence of an intervertebral disk syndrome with nerve root involvement or any bowel, bladder or erectile dysfunction. The neurologic examination was unremarkable. X-ray s of the thoracic spine documented degenerative arthritic c hanges and X -rays of the lumbar spine revealed degenerative arthritic changes at L4/L5.

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 ~ 5 Mo. Pre-Sep
VA C&P ~ 2 Mo. Post-Sep
Flexion (90 Normal) 70/70/70 70
Extension (30) 15/15/15 15
R Lat Flexion (30) 25/27/25 30
L Lat Flexion (30) 30/30/30 30
R Rotation (30) 30( 50/55/55 ) 30
L Rotation (30) 30( 55/50/50 ) 30
Combined (240) 200 205
Comment Inclinometer used except for rotation. No pain on motion; DeLuca negative
§4.71a Rating - 10 %
invalid font number 31502
The Board directed attention to its rating recommendation based on the above evidence. The IPEB assigned a 0% rating using code 5299-5237 (lumbosacral or cervical strain) for chronic radiating LBP. The VA assigned a 10% rating using code 5237 for degenerative arthritis, although the VARD indicated a service-connection for degenerative arthritis of the cervical, thoracic and lumbosacral spine. The Board must establish a functional impairment linked to fitness in order to recommend a separate rating for radiculopathy associated with unfitting spine conditions; a threshold not reached by the evidence in this case. 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 concluded that any radiculopathy or radicular symptoms could not be recommended for additional disability rating. The Board noted the MEB examination ROM measurements were performed with both an inclinometer and goniometer thereby affording less probative value to the MEB examination than the VA examination performed 2 months after separation. However, both examinations were the same for the flexion ROM thereby affording a 10% rating, which was confirmed by the combined ROM that also supported a 10% rating. In the absence of muscle spasm or guarding resulting in an abnormal gait, an abnormal spinal contour, or sufficient incapacitating episodes, a 20% rating is not warranted. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the lower back condition.

Contended PEB Condition-Neck Pain. The Board’s main charge is to assess the fairness of the PEB’s determination that neck pain was not unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The neck pain was not profiled or implicated in the commander’s statement, but was judged to fail retention standards. An orthopedic evaluation was performed on 10 March 2006 and noted the CI had neck pain since grade school. Examination revealed limited decreased ROM with extension of the neck. A PT evaluation on 22 March 2006 indicated onset of the neck pain was insidious and had been present for years. Symptoms increased during deployment several years earlier when the CI wore personal protective equipment and carried a weapon. However, he did not seek medical attention. Prior treatment with neck strengthening years earlier did not change the symptoms. Pain was constant and dull from 5/10 in severity to 7/10 with cervical extension. He denied headaches, but noted numbness in the left axilla (arm pit) which radiated into the medial arm. The CI was of large build with good shoulder posture and slight forward head posture. ROMs for the cervical spine were: Flexion 45 degrees, extension 50 degrees with pain at the base of the cervical spine, bilateral lateral flexion 30 degrees, and bilateral rotation 65 degrees. Neurologic examination was unremarkable.

The NARSUM dated 22 March 2006 noted an MRI C-spine showed C4/5 and C5/6 spondylosis (a defect in the connection between he vertebrae), and left C5/6 neuroforaminal (where the nerves exit the spine) narrowing and examination demonstrated a full ROM of the neck and a negative Spurling’s compression test (to determine cervical radiculopathy). The VA examination of the cervical spine revealed no pain on movement, no muscle spasm, no tenderness and no evidence of any ankylosis. The cervical spine ROM was normal and was not limited by pain and was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination. An X -ray series of the cervical spine revealed degenerative arthritic changes at C4/C5 and loss of cervical lordosis. All of the aforementioned was reviewed and considered by the Board. There was no performance based evidence from the record that the neck pain significantly interfered with satisfactory duty performance. 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 neck condition and so no additional disability rating is 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. 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 radiating LBP condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a. In the matter of the contended neck pain condition, the Board unanimously recommends no change from the PEB determination of not unfitting. There were no other conditions within the Board’s scope of review for consideration.
RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION VASRD CODE RATING
Chronic Radiating Low Back Pain 5237 10%
RATING 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131106, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record


XXXXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXXXXXX , AR20150012460 (PD201302204)
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 10% 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                                                  XXXXXXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA



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