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AF | PDBR | CY2013 | PD-2013-02240
Original file (PD-2013-02240.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02240
BRANCH OF SERVICE: Army  BOARD DATE: 20140819
SEPARATION DATE: 20050719


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (15U/Chinook Crewman) medically separated for a chronic back and left leg pain condition. The 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 and left leg condition, characterized as “chronic low back pain (LBP) spasm with left upper leg pain/numbness s/p L3-4 left discectomy,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic back and left leg pain post L3/L4 discectomy” as unfitting, rated 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “20% for my back injury is insufficient considering the pain I experience on a daily basis. It makes daily activities difficult at best and some days unbearable!”


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 low back and left leg condition are addressed below; and, 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 Admin IPEB – Dated 20050415
 VA - (2 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Low Back and Left Leg Pain 5237 10% Spondylosis Lumbar Spine w/Residuals of Discectomy to include Scar 5242 20% 20050511
Lumbar Radiculitis 8520 0% 20050511
Other x 0 (Not in Scope)
 Other x 13 (Not in Scope) 20050511
Combined: 10%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 20051201 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Low Back and Left Leg Pain Condition. The narrative summary notes that while deployed in September 2002, approximately 3 years prior to separation, following heavy work the previous day, the CI woke up with LBP that radiated to the left thigh with muscle spasm. The CI was evaluated by neurosurgery and was noted to have decreased sensation and mild weakness in the muscles of hip flexion and rotation (iliopsoas/quads) consistent with a radiculopathy in the L3 nerve root distribution. He was treated conservatively until lumbar myelogram, CT and a magnetic resonance imaging (MRI) showed a herniated disc at the L3-4 level with nerve impingement; and then had a lumbar discectomy in May 2004. Following surgery the CI reported that his leg symptoms were much better. Approximately 3 months later he had recurrent leg pain with numbness/tingling, mostly in the thigh, after carrying heavy bags. A repeat MRI after surgery showed scarring of the left L3 nerve root and scar tissue moderately compromising the nerve foramen. Despite additional treatment the CI continued to report primarily back pain with some numbness/tingling to the left thigh area, but was noted to have good strength, sensation and reflexes. A repeat myelogram did not indicate any further nerve compression and no further surgical intervention was recommended.

At the MEB examination performed on 9 March 2005, approximately 4 months prior to separation, the CI reported chronic pain increased by activity and partially improved with daily pain medications and left leg weakness. The MEB physical exam noted an antalgic limp on the left and tenderness to palpation of the lumbar spine with muscle spasm. Neurological evaluation was intact in both lower extremities and there were no other reported neurological symptoms. Pain with range-of-motion (ROM) was noted. Physical therapy measured ROM for the MEB performed on 25 February 2005 noted thoracolumbar (TL) flexion (with three measurements) of 28 degrees, 30 degrees, 30 degrees with a combined TL ROM of 108 degrees. There were no episodes of incapacitation due to the back condition noted in the records.

At the VA Compensation and Pension (C&P) exam performed 2 months prior to separation, the CI reported LBP and numbness/tingling of the left lower extremity (LLE). The CI’s listed medications included pain medication and a muscle relaxant. The examination noted a normal gait and posture, with normal strength, sensation and reflexes throughout. Straight leg raise testing was negative bilaterally and there was no radiation of pain noted with ROM. Lumbar ROM was flexion of 40 degrees with a combined TL ROM of 170 degrees. The examiner indicated that there was no further loss of ROM with repetitive ROM. Lumbosacral X-rays noted mild degenerative changes at the lower lumbar levels. The VA examiner separately addressed the reported persistent numbness/tingling of the LLE and noted there were no sensory deficits, abnormal reflexes, muscle tenderness or pain with flexion or extension motions of the hip, knee or ankle. The examiner indicated there was no current pathology present on examination to render a diagnosis for the LLE numbness/tingling.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the low back and left leg pain condition 10%, coded 5237 (lumbosacral strain) and the VA rated it 20%, coded 5242 (spine arthritis). The Board reviewed the evidence to see if a higher evaluation than 10% was achieved coding IAW VASRD §4.71a. The Board considered that at the MEB examination the CI had TL ROM limited to 30 degrees or less, with muscle spasm and a limp noted, but at the prior to separation C&P examination, more proximate to the date of separation, the CI had TL flexion of 40 degrees and a normal gait, without spasm. The Board agreed that the CI’s disability due to the back condition most closely met the 20% IAW VASRD General Rating Formula for Diseases and Injuries of the Spine which includes among its specifications “forward flexion of the thoracolumbar spine of greater than 30 degrees but not greater than 60 degrees.” The Board agreed that the next higher evaluation of 40% was not met because TL ROM was not permanently limited to 30 degrees. The MEB examination was consistent with the consequences of acute muscle spasm, which also supports the 20% rating based on the criteria of “muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour…” The Board reviewed to see if a higher evaluation for the LBP condition could be achieved by rating intervertebral disc syndrome based on incapacitating episodes, specified by the VASRD spine rules as “. . . requires bed rest prescribed by a physician and requires treatment by a physician,” but there were no incapacitating episodes documented in the available records.

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy. At both the MEB and VA examinations the CI was noted to have normal strength, sensation and reflexes. At the VA examination the CI had a normal gait without muscle tenderness or muscle spasm present. At the C&P examination the VA examiner addressed the reported leg numbness/tingling symptom and concluded that there was no evidence of pathology present on the examination. The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting. Therefore the critical decision is whether or not there was a significant motor or sensory weakness which would impact military occupation specific activities. The left leg symptoms were not profiled. The commander’s statement noted that the CI’s leg pain limited his ability to stand but radiating pain from the back condition is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” There is no evidence in this case that the radiating numbness/tingling symptoms without objective sensory deficit could be described as functionally impairing. The Board concluded therefore that this condition could not be recommended for additional disability rating. The Board agreed to code the back condition as 5242-5243 as it was medically consistent with the CI’s history of intervertebral disc syndrome with findings of lumbar degenerative changes on imaging studies. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% 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 low back and left leg pain condition, the Board unanimously recommends a disability rating of 20%, coded 5243-5242 IAW VASRD §4.71a. 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:

UNFITTING CONDITION VASRD CODE RATING
Chronic Low Back and Left Leg Pain 5243-5242 20%
COMBINED 20%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131112, 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, AR20150003238 (PD201302240)
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 20% 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                                                  XXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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