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AF | PDBR | CY2013 | PD-2013-02285

Original file (PD-2013-02285.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX CASE: PD-2013-02285
BRANCH OF SERVICE: Army BOARD DATE: 20141121

SEPARATION DATE: 20050724

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (35E/Radio and Communications Security Repairer) medically separated for lumbar spine degenerative disc disease (DDD). The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The condition, characterized as “lumbago degenerative lumbar spine L4-L5 facet joints fused” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also forwarded “atypical squamous cell” as medically acceptable. The Informal PEB adjudicated “lumbar spine degenerative disease, without neurologic abnormality” as unfitting, rated at 10%, with probable application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) . The CI made no appeals and was medically separated.

CI CONTENTION: “It may be inaccurate. The unfitting condition of degenerative disc disease, lumbar spine may have had an inaccurate rating of 20%. A 40% rating was awarded effective 11-3-2011. I have also been rated for other conditions-PTSD 70% 10/24/2011-Right ACL joint strain 10% 10/24/2011-mid left lower extremity lumbar radiculopathy 10% 11/3/2011”.

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 lumbar degenerative disc disease condition is addressed below as is the contended radiculopathy. The CI did not contend for the not unfitting “atypical squamous cell” condition and it is therefore outside the Scope of the Board. The post-traumatic stress disorder (PTSD) and right anterior cruciate ligament (ACL) conditions were not considered by the PEB and are not in scope. 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 IPEB – Dated 20050606	VA* - Based on Service Treatment Records (STR)
Condition	Code	Rating	Condition	Code	Rating	Exam
Lumbar Spine DDD…	5242	10%	DDD, Lumbar Spine	5299-5243	20%	STR
Rating: 10%	Combined: 20%

Derived from VA Rating Decision (VA RD ) dated 20 050815 (most proximate to date of separation )

ANALYSIS SUMMARY:

Degenerative Disc Disease, Lumbar Spine Condition. On 3 May 2002, the CI was initially treated for left hip pain. The first evaluation for low back pain (LBP) on 17 October 2002, was unremarkable and the CI had full range-of-motion (ROM), she was given duty limitations and medications with apparent resolution of her complaint. In November 2002 during her deployment, the CI again reported LBP which was believed to be “aggravated” by the CI sleeping on a cot and/or the floor; she denied any specific trauma. On 25 February 2004, the CI stated that she experience LBP after stretching. She was given medications and referred to chiropractic therapy and while attending initial appointment on 3 March 2004, the examiner noted that the CI had full ROM with pain on flexion. On 21 May 2004, she was evaluated in the primary care clinic for ongoing LBP with a reported 12 months history of hip pain. An examiner noted congenital abnormalities on lumbar X-rays and a magnetic resonance imaging obtained 7 June 2004, revealed a herniated disc at L5 on the left with a congenital partial fusion of L4-L5. A following primary care visit on 1 July 2004; the examiner noted a reduction in the ROM, demonstrated by the CI’s fingertips being unable to reach beyond 6 inches to the floor, for flexion over 60 degrees, extension of 15 degrees and side bending of 30 degrees bilaterally. Sensation was decreased over the entire left foot (non-anatomical). A week later, she was evaluated in the pain clinic and noted to have normal motor and sensory examinations with one painful maneuver which was not expected to cause pain for this particular condition; three such maneuvers were again positive for pain the following day on re-examination.

During the physical therapy evaluation on 10 August 2004, the examiner noted that the CI had decreased sensation of her entire left leg in a non-dermatomal distribution (non-anatomical), ability to sit-upright, but changed position frequently and her ROM was reduced to 50% for both flexion and extension, but normal for rotation. The examiner also noted that she was able to flex fully to put on her socks/shoes and performed a pain free self-transferred from a lying “prone” position to sitting position. 5/5 maneuvers that were not expected to cause pain were painful. During the 20 October 2004 physical therapy evaluation, flexion and extension remained reduced to 50% on measurement, but testing for nerve root irritation was inconsistent. Maneuvers not expected to cause pain were positive.

A primary care provider examination on 15 November 2004, the examiner noted full ROM and a normal gait. One week later, in physical therapy, the CI’s ROM was normal for flexion, but painful in extension and left side bending. The motor examination, gait and posture were normal. Maneuvers not expected to be painful, tested positive. The physical therapy examination on 14 January 2005, were similar in findings with flexion in excess of Veterans Affairs 90 degrees normal value at 120 degrees and painful extension and left side bend. The motor examination, gait and posture were again normal. Four maneuvers not expected to be painful were pain positive. Another physical therapy evaluation dated 11 March 2005 to obtain the goniometric ROM measurements, flexion was limited to 45 degrees and the combined ROM was 160 (normal is 240 degrees).

The narrative summary (NARSUM) dated 18 May 2005 (2 months prior to separation); the examiner noted that the CI did not responded adequately to treatment, her gait, posture and motor function were normal except for the bilateral hip flexors that were not consistent with the remainder of the examination. Five maneuvers not expected to be painful were positive. Signs of atrophy were absent and neither incapacitation nor spasm was recorded.

There was no VA Compensation and Pension (C&P) examination proximate to separation and the first in evidence was over 4 years after separation, therefore not probative for the disability at separation.

The Board directed its attention to its rating recommendation based on the above evidence. The PEB coded the back condition as 5242 (degenerative arthritis of the spine) and rated at 10%. The VA coded the back condition as (5299-5243) analogous to intervertebral disc syndrome, but rated at 20% and citied the MEB’s ROM values which supported a 20% rating. There were no other goniometric measurements in evidence proximate to separation. The Board therefore considered the probative value of these measurements, weighed against the totality of evidence available for review. The ROM was typically noted as full and for those examinations in which the flexion and extension were noted to be limited by 50%, the CI was observed to be able to put on her socks and tie her shoes without signs of discomfort or distress and to perform a pain-free self-transition from lying “prone position” to sitting position; the measured ROM was not consistent with the observed level of function. During multiple appointments, maneuvers not expected to be painful did, in fact, elicit pain. Nonetheless, the Board determined that the ROM measured for the MEB was not consistent with the preponderance of evidence and therefore, not reflective of the CI’s level of disability at separation. With the absence of spasms, incapacitation, or ankylosis, the Board found no route to a rating higher than the 10% adjudicated by the PEB. The Board also considered if an unfitting radiculopathy was present at separation. The motor examination was typically normal as was the gait. The sensory examinations were inconsistent and the sensory loss did not follow an anatomical distribution. The Board determined that the evidence does not support the presence of an unfitting radiculopathy condition at separation and no rating can be recommended. 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 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 lumbar spine degenerative disease… 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 20131104, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXX
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 Re commendation for XXXXXXXXXXXXXX AR20150006480 (PD201302285)

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                                                  XXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR

( ) DVA

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AF | PDBR | CY2013 | PD-2013-02285

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