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AF | PDBR | CY2013 | PD-2013-02518
Original file (PD-2013-02518.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-02518
BRANCH OF SERVICE: Army  BOARD DATE: 20150804
SEPARATION DATE: 20050609


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Reserve O3 (Tactical Intel) medically separated for a thoracolumbar spine condition which could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty. She was issued a permanent U3/L3 profile and referred for an Medical Evaluation Board (MEB). Thoracic back pain secondary to kyphosis (abnormal forward bowing of the spine) and low back pain secondary to degenerative disk disease (DDD) were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated thoracic and low back pain with imaging findings of DDD as unfitting, rated 10% citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: She was not evaluated for hearing loss. Her complete submission is at Exhibit A.


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 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 20050209
 VA* (2 Mo. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Thoracic and Low Back Pain 5237 10% Thoracolumbar DDD and DJD 5242 10% 20050407
Other MEB/PEB Conditions x 0 (Not In Scope)
 Other x 6
RATING: 10%
 RATING: 10%
* Derived from VA Rating Decision (VA RD ) dated 200 50801 (most proximate to date of separation [ DOS ] )


ANALYSIS SUMMARY:

Thoracolumbar Spine. The earliest entry in the available service treatment record (STR) for back pain is from 1991, mentioning a 3-year history of intermittent pain since childbirth. The CI developed an acute onset of persistent pain with left lower extremity (LLE) radiation, associated with heavy lifting, in June 2000 (5 years prior to separation). Magnetic resonance imaging from that period demonstrated mild disc disease (bulge T10/11, DDD L1/2) with no spinal cord or nerve root impingement. A neurosurgical consultant opined that there were no surgical indications; and, a neurology consultant in November 2003 documented detailed normal neurologic findings (5/5 strength) and a normal gait. The CI was managed conservatively for a protracted period until worsening severity required MEB referral. There are no STR entries commenting on range-of-motion (ROM). There is one entry (12 months prior to separation) which records an antalgic gait; but, there are earlier entries and one from April 2005 (2 months prior to separation) noting a normal gait. There are various entries denying subjective weakness and documenting normal neurologic findings, and none to the contrary. There are no entries documenting abnormal spinal contour or periods of incapacitation.

The MEB narrative summary (NARSUM) was conducted 14 July 2004 (11 months prior to separation); and, the examiner noted persistent back pain with LLE radiation; but, did not elaborate the frequency or severity of symptoms, and specified only profile restrictions for functional limitations. The NARSUM also documented the radiologic findings of “slight kyphosis, measuring approximately 45⁰” which accounted for one of the MEB’s submitted diagnosis. The physical examination recorded “antalgic gait complaining of pain at the left leg” and documented normal neurologic findings. The examiner noted painful motion with grossly normal ROM based on estimation and anatomical markers. Measured ROM (goniometry) for the MEB was normal in all planes (flexion 90 degrees, combined 240 degrees).

A VA Compensation and Pension (C&P) examination was conducted 7 April 2005 (2 months prior to separation), and documented moderate back pain with LLE radiation present “approximately 50% of the time” and rated 5/10. The only functional limitation noted was heavy carrying. The VA physical examination recorded normal gait and spinal contour, tenderness (no comment regarding spasm), and normal neurologic findings (5/5 strength); with grossly normal observed ROM and no comment regarding painful motion.

The Board directed attention to its rating recommendation based on the above evidence. The PEB’s 10% rating under code 5237 (Lumbar strain) was consistent with VASRD §4.71a criteria for the Service ROM evidence; and, the VA’s 10% rating under 5242 (Degenerative arthritis of the spine) likewise complied with §4.71a based on the C&P evidence. There is no conflicting ROM evidence in this case which would challenge a 10% rating. Members deliberated whether the NARSUM evidence for antalgic gait was sufficiently probative to support a 20% recommendation based on that §4.71a criterion. Although there is competing evidence from the STR and the C&P examiner, there is also STR evidence corroborating that antalgic gait at least intermittently resulted from the back condition. Members thus agreed that reasonable doubt favored concession of that criterion in support of the higher rating. The Board considered whether additional Service rating could be recommended under a peripheral nerve code for the LLE radicular symptoms present at separation, but members agreed that neither the functional link to fitness requisite for Service rating nor the presence of a VASRD ratable deficit were supported by the evidence. There was no documentation of incapacitating episodes which would support a higher rating under that formula. After due deliberation, considering all of the evidence and conceding VASRD §4.3 (Reasonable doubt), the Board recommends a 20% rating for the thoracolumbar spine condition, proposing code 5242 for its clinical compatibility.


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 thoracolumbar spine condition, the Board unanimously recommends a disability rating of 20%, coded 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 her prior medical separation:

CONDITION
 VASRD CODE RATING
Degenerative Disc Disease, Thoracolumbar Spine 5242 20%
RATING
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131130, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








XXXXXXXXXXXXXXX
President
DoD 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 , AR20150015578 (PD201302518)
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                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA
                 

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