Search Decisions

Decision Text

AF | PDBR | CY2013 | PD-2013-02274
Original file (PD-2013-02274.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX   CASE: PD-2013-02274
BRANCH OF SERVICE: Army  BOARD DATE: 20150305
SEPARATION DATE: 20040128


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Tank Turret Repairer) medically separated for a back condition. The back 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 “lumbar DDD and facet spondylopathies,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “lumbar DDD, w/o [without] abnormality” as unfitting, rated 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: The CI writes: “Back issues started well within my time in service, ultimately affecting my wellbeing physically, my relationship with my wife (intimacy), and many experiences with my children, i.e., picking them up, playing with them, running, etc. The pain consistently effects my sleep. Until this day, I never ever get a complete nights rest without daily medication, which has had negative impact on my stomach. Once it was deemed that I was assessed an unfair rating, the government takes money away from me. I still can’t run, I limp at times , can’t sit or stand for extended periods, and have a problem with intimacy.”


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 20031107
 VA* - (~1 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
LUMBAR DDD… 5299-5237 0% LUMBAR DDD… 5299-5242 0% 20031217
Other x 0 (Not In Scope)
 Other x 5
RATING: 0%
 RATING: 10%
* Derived from VA Rating Decision (VA RD ) dated 200 40506 (most proximate to date of separation ( DOS ) ) . The 10% rating is based upon multiple, non-compensable, service connected disabilities.

ANALYSIS SUMMARY:

Lumbar Degenerative Disc Disease (DDD), with out Neurologic Abnormality. The CI was evaluated for low back pain with a magnetic resonance imaging on 10 January 2003. It showed multilevel DDD with a disc herniation at L4-5. Conservative management with medications, duty limitations, and injections were not adequate for the CI to return to full duty status and he was entered into the MEB process. The narrative summary dated 15 September 2003 recorded a normal neurological examination with para-lumbar tenderness, but without spasm (normal tone). A range-of-motion (ROM) was obtained a month later and is charted below. Electrodiagnostic studies on 25 September 2003 were consistent with a right sided L5 radiculopathy. At the MEB examination on 22 October 2003, the CI reported severe back pain since 2002. The CI had pain with forward flexion. The neurological examination was checked normal. The MEB ROM measurements were on 31 October 2003. The examiner noted that the extension was reduced secondary to an increased lordosis (normal lumbar curve) at rest. The flexion was greater than the VA normal value.

At the VA Compensation and Pension (C&P) exam performed on 17 December 2003, a month prior to separation, the CI reported a 1-year history of back pain without antecedent trauma. Incapacitation was not recorded and there was no use of assistive devices. On examination, the gait and posture were normal; ROM was painless and full. The neurological examination was normal. The back was non-tender.

The goniometric 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)		 MEB ~3 Mo. Pre-Sep VA C&P ~1 Mo. Pre-Sep
Flexion (90 Normal) 90 (95/95/95) 90
Combined (240) --- 240
Comment Extension reduced secondary to increased lordosis Painless motion
§4.71a Rating 10% (4.59) 0 %

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the back at 0% for forward flexion greater than 90 degrees. The reduced extension supports a higher rating of 10%; however, the examiner specifically noted that this was secondary to increased lordosis. The VA C&P examination values were either normal or greater than VA normal values. The Board considered the evidence. The VASRD specifically notes that a reduced ROM can be considered normal when secondary to body habitus (VASRD §4.71a Note 2); this is the case here. The MEB ROM values can then be considered to be normal as was noted by the VA examiner. However, the MEB examiner documented that forward flexion was painful which supports a 10% rating under VASRD §4.59 (painful motion). The evidence does not support the presence of an unfitting neuropathy at separation. 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 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 back condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.59 and §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:

CONDITION VASRD CODE RATING
Lumbar Degenerative Disc Disease 5237 10%
COMBINED 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131108, 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 XXXXXXXXXXXXXXXXXXXX , AR20150012445 (PD201302274)
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 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                                                  XXXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA




Similar Decisions

  • AF | PDBR | CY2013 | PD-2013-01871

    Original file (PD-2013-01871.rtf) Auto-classification: Denied

    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 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. Post-Separation) ConditionCodeRatingConditionCodeRatingExam Chronic...

  • AF | PDBR | CY2014 | PD-2014-02147

    Original file (PD-2014-02147.rtf) Auto-classification: Denied

    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 range-of-motion (ROM) and neurological examination were normal. The radiculopathy condition was reviewed and considered by the Board.

  • AF | PDBR | CY2013 | PD-2013-01900

    Original file (PD-2013-01900.rtf) Auto-classification: Denied

    SEPARATION DATE: 20040310 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 back condition and IAW VASRD §4.71a, the Board unanimously recommends...

  • AF | PDBR | CY2013 | PD-2013-01997

    Original file (PD-2013-01997.rtf) Auto-classification: Denied

    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. Active ROM “was hands to her toes, and up with slight knee flexion; good lateral bending, rotation, and extension without pain.” Neurologic examination was unremarkable. Service Treatment Record Exhibit C. Department...

  • AF | PDBR | CY2012 | PD 2012 00686

    Original file (PD 2012 00686.txt) Auto-classification: Approved

    Chronic Low Back Pain due to Degenerative Disc Disease and Bertotolli’s Syndrome Condition. The remote from separation, VA exam in November 2006, documented slight pain-limited ROM and the VA continued their 10% rating based on that exam. The exams were about the same time prior to and after separation.

  • AF | PDBR | CY2014 | PD 2014 00415

    Original file (PD 2014 00415.rtf) Auto-classification: Denied

    Low Back Pain Condition . The Board noted that the CI does not state when the nerve block was accomplished nor specify which evaluation followed it in his contention. I have carefully reviewed the evidence of record and the recommendation of the Board.

  • AF | PDBR | CY2013 | PD 2013 01206

    Original file (PD 2013 01206.rtf) Auto-classification: Denied

    The rating for the unfitting back condition is addressed below; and, as well as the contended, hypertension, hyperlipidemia, patellofemoral pain syndrome (PFPS), coronary artery disease (CAD) and paroxysmal atrial tachycardia (PAT) which are within the DoDI 6040.44 defined purview of the Board. He was noted the have normal, but painful, range-of-motion (ROM) of the lumbosacral back. Spasm was absent.A permanent L3 profile was issued on 18 December 2007 for low back pain with restrictions...

  • AF | PDBR | CY2013 | PD-2013-02289

    Original file (PD-2013-02289.rtf) Auto-classification: Approved

    The MEB only referred “chronic neck pain” and “chronic low back pain” to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB physical examination noted decreased range-of-motion (ROM) of the cervical areas and tenderness with spine palpation.The narrative summary (NARSUM) dated 7 April 2004 noted the CI could not perform the duties of his MOS secondary to chronic low back and neck pain.A permanent profile U3/L3dated 12 May 2004 was issued for neck pain, CTS and a chronic lower back...

  • AF | PDBR | CY2012 | PD2012-00226

    Original file (PD2012-00226.docx) Auto-classification: Denied

    The Physical Evaluation Board (PEB) adjudicated the lumbar fusion L2-L3 condition as unfitting, rated 20%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). Lumbar Fusion L2-L3 Condition . In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandum, approve the recommendations of the PDBR that the following individuals’ records not be corrected to reflect a change in...

  • AF | PDBR | CY2013 | PD2013 00224

    Original file (PD2013 00224.rtf) Auto-classification: Approved

    Separation Date: 20040223 The rating for the unfitting low back condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board. Physical Disability Board of Review