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AF | PDBR | CY2013 | PD-2013-02590
Original file (PD-2013-02590.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02590
BRANCH OF SERVICE: Army  BOARD DATE: 20140826
SEPARATION DATE: 20070628


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSGT/E-6 (68W30/Health Care Specialist) medically separated for a chronic mid back pain condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) however, was able to perform and alternate fitness test. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The back condition, characterized as “T12 compression fracture with recalcitrant activity associated back pain,” was forwarded to the Physical Evaluation Board (PEB). No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic mid back pain” 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: “An alternate increased rating for diagnosis secondary to primary injury during term of active duty service and deployment during active duty status, were issued on 06/29/2007 and 10/29/2010. These diagnoses were established as service connected disabilities.


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 mid back pain condition is addressed below. Additionally, in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose mental health (MH) diagnoses were changed during that process, the CI’s case file was reviewed regarding diagnosis change, fitness determination and rating of unfitting MH diagnoses in accordance with the VASRD §4.129 and §4.130. 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 20070517
 VA - (3 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Mid Back Pain 5235 10% DJD L/Spine and s/p T12 Compression w/Residual Cauda Equina and Voiding Dysfunction 5242 10% 20070925
PTSD Not Rated PTSD w/Secondary Depression 9411 50% 20071025
Depression Not Rated
No Additional MEB/PEB Entries in scope
 Other x 5
Combined: 10%
 Combined: 60%
Derived from VA Rating Decision (VA RD ) dated 20080123 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board considers VA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Mid-Back Pain Condition. Available treatment records document that the CI fell 9 feet from a motorcycle (dirt bike) on 3 October 2004 and reported low back pain and left buttock numbness. The physical examination in the emergency room showed marked tenderness around the thoracic (T12) vertebra and left buttock contusion. X-rays demonstrated a compression fracture to T12. There was no kyphosis (exaggerated rounding of the back). He received pain medication and was placed into a cast brace and then converted to thoracolumbar orthotic (back brace used for support and to limit motion) for 4 months. Prolonged sitting, house cleaning and general activity aggravated the pain. He developed bladder incontinence treated with Detrol. He received physical therapy and his condition improved; he was able to run 1-2 miles and walk without an increase in pain. He eventually deployed to Iraq from 13 September 2005 to 15 January 2006, but he developed back spasms with mission activities and while on patrol. The CI performed push-ups and strengthening exercises for his back and was able to complete his deployment. He received a U3 profile for the T12 compression fracture and was referred to the MEB in January 2007.

The narrative summary dated 15 March 2007 notes that the CI reported activity related thoracolumbar back pain and left buttock and midline sacral area numbness. He had painful activity associated with a “click” in the lower thoracic spine, pain that radiated down and up, decreased sensation along the left buttock and coccyx area and constant back pain. Pain was 2-3/10, which increased to 8/10 with activities like running, jumping, overhead lifting or trunk flexion. He was unable to perform load bearing activities or physical training without exacerbation of his pain, but he had no neurological complaints. Urinary incontinence persisted, but had improved with medication. During the physical examination, the CI revealed that he maintained the tripod position as the most comfortable position (sitting with his hands on his thighs or with his palms flat on the examination table behind him). The physical examination was significant for pain, localized to the posterior aspect of T12 and limited his range-of-motion (ROM): forward flexion 55 degrees, extension 10 degrees, left lateral bending 20 degrees, right lateral bending 25 degrees and trunk rotation 45 degrees. There was mild-moderate tenderness to palpation at T12 and a syrinx (fluid filled cyst) at T8-9, 10mm in length and 1 mm at maximum diameter. Magnetic resonance imaging showed syrinx visualized at T11-T12 and early degenerative changes at L1-L2 and L2-L3. There was no increase in kyphosis at T12. The diagnosis rendered was T12 compression fracture with recalcitrant activity associated back pain.

At the VA Compensation and Pension (C&P) examination on 25 October 2007, 4 months after separation, the CI reported slight sensory impairment at the site of the fracture at the thoracolumbar junction and in the lower sacral area extending to the gluteal fold along the left side of the buttock. He reported issues with bladder control, but not bowel control. He reported chronic mid back pain at the thoracolumbar junction which was aggravated by bending, lifting, rotating the trunk and prolonged sitting. He endorsed more intense back pain about once a month that lasted for 2 days, but he was able to work through it. He was able to drive with frequent breaks. The physical examination revealed some trunk guarding, but general comfort. He had a normal gait and posture and could toe and heel walk. He had reduced lumbar lordosis and reduced ROM of the lumbosacral spine. Motions of the trunk (thoracic) were guarded and slow. He had pain with motion and ROM of right and left 15 degrees each, forward bending to 80 degrees at the level of the hips, spinal extension to 10 degrees and trunk rotations 20 degrees each. Reflexes of both knees and ankles were 2+. Straight leg raising was normal with no sensory or motor deficits in the lower extremities. Tenderness and decreased sensation were noted in the midline and paraspinal areas of the mid back. There was also decreased sensation over the lower sacral area and part of the left buttock. DeLuca examination of the lumbosacral spine revealed some guarding of trunk motions, but no loss of ROM, no aggravation of pain and no obvious fatigue. The diagnoses rendered were status post (s/p) T12 compression fracture with residual chronic pain, degenerative joint disease (DJD) of upper lumbar spine with chronic pain without lumbosacral radiculopathy, some sensory impairment over the tail bone and adjoining gluteal fold and left buttock, some bladder control issues.

The Board directed attention to its rating recommendation based on the above evidence. The PEB adjudicated the chronic mid back pain condition as unfitting with a disability rating of 10% coded 5235 (vertebral fracture). The VA rated the DJD L/spine and s/p T12 compression w/residual cauda equina and voiding dysfunction at 10% coded 5242 (degenerative arthritis of the spine). The Board determined that there was no evidence of a combined ROM of the thoracolumbar spine less than 120 degrees, muscle spasms, or guarding severe enough to result in abnormal gait or spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis for a 20% disability rating under the General Rating for Diseases and Injuries of the Spine. 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 chronic mid back pain condition.

Mental Health Review. At the C&P evaluation, the CI complained of “lack of emotion and cried over stupid stuff.” He reported he saw combat in Iraq and worked as a combat medic, exposed to numerous American and Iraqi casualties. The most painful was seeing a wounded boy, the same age as CI’s oldest son, cry for his father. The CI reported sleep problems, occasional nightmares, night terrors, intrusive memories of the war, exaggerated startle response, hypervigilance, frequent depression, 20-pound weight loss in past year and he drank 24-26 beers during the week. The mental status examination was normal, but the examiner noted reports of peritraumatic dissociative episodes that began in Iraq and still occurred when he is working in the emergency room (ER). He worked full-time in the ER, attended school for a nursing degree and was undergoing a divorce while living with his parents. He reported he “loved saving people” and got along with others. Diagnoses of posttraumatic stress disorder (PTSD) with secondary depression and alcohol abuse secondary to PTSD were rendered with a Global Assessment of Function of 50 (moderate).

All available evidence was reviewed by the action officer and considered by the Board. There was no performance based evidence from the record (e.g. commander’s statement) that the depression and anxiety symptoms significantly interfered with satisfactory duty performance. A mental illness was never profiled. There was only one service MH record dated 2005 with a diagnosis of adjustment disorder. The CI indicated on the DD Form 2707 that he had a history of depression and PTSD and was being followed by MH. He was not taking any psychiatric medications. A VA examiner rendered an Axis I diagnosis of PTSD and alcohol abuse 4 months after separation. The SRP reviewed the records for evidence of inappropriate changes or elimination of diagnosis of the MH condition during the Disability Evaluation System (DES) processing and found none. The SRP agreed that this applicant did not appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project.

The SRP noted the service treatment note with a diagnosis of adjustment disorder rendered 2 years prior to separation and the VA diagnosis of PTSD rendered 4 months after separation. The SRP considered whether the MH condition diagnosed by the VA psychiatry evaluation, regardless of specific diagnosis, was unfitting for continued military service. The CI, by his account, performed the duties of his MOS while deployed and did a good job in his new duties post-deployment. There were no psychiatric emergency visits, no active suicidal or homicidal thoughts; no legal issues no reports of domestic violence or any psychiatric hospitalizations. The commander’s statement did not implicate an MH condition, but indicated that the CI was doing an outstanding job and was one of his best leaders. The commander’s statement and self-assessment by CI of his interest and dedication to his work indicated that he was not functionally impaired in his duties due to psychiatric issues. No MH condition was profiled or judged to fail retention standards. There was no indication from the record that any MH condition significantly interfered with satisfactory duty performance. The SRP concluded that the preponderance of evidence did not support an unfit determination for any MH disorder at the time of separation, therefore; VASRD §4.130 and §4.129 do not apply.


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. PEB reliance on regulatory guidance contained in AR 635-40, paragraph B-24f (restricting the maximum rating for pain, regardless of how many separate anatomical sites, to 20%) for rating the chronic mid back pain without neurologic abnormalities condition was operant in this case and the condition was adjudicated independently of that policy/guidance memorandum by the Board. In the matter of the chronic mid back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the MH review, the Board cannot recommend an additional disability rating. 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 20131206, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                                   
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX , AR20150006260 (PD201302590)

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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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