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AF | PDBR | CY2013 | PD-2013-02646
Original file (PD-2013-02646.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02646
BRANCH OF SERVICE: Army  BOARD DATE: 20150811
SEPARATION DATE: 20041104


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Infantryman) medically separated for chronic low back pain (LBP). The back condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). His profile allowed for an alternate aerobic event to satisfy physical fitness standards. Chronic LBP was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated chronic low back pain as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: He was not evaluated properly. His 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/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 20040618
 VA* - (~2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain… 5299-5237 10% Myofascial Pain Syndrome, Lumbar 5236-5237 Deferred → 10% 20050106
Other MEB/PEB Conditions x 0 (Not In Scope)
 Other x 13
RATING: 10%
 RATING: 50% → 70%
* Derived from VA Rating Decisions (VA RD ) dated 200 50511 and 20050623 (most proximate to date of separation ( DOS ) ) .





ANALYSIS SUMMARY:

Chronic Low Back. The CI first reported LBP with subsequent left leg paresthesia after being in a Bradley vehicle rollover accident in 1997. His painful symptoms persisted throughout the balance of his service career. Initial and subsequent spinal X-rays revealed no pathologic abnormality and electro-diagnostic studies were normal. Despite aggressive physical therapy, spinal manipulation, pain management, local injections, and narcotic medication, his symptoms remained. He was permanently profiled in November 2003 with a diagnosis of “chronic LBP” and referred to an MEB. The commander’s statement noted that the CI was incapable of performing his MOS duties due to “chronic lower back problems.” There were no periods of incapacitation. At the MEB narrative summary examination on 12 March 2004 (8 months prior to separation), the CI endorsed a constant sharp LBP additionally described as a stiffness, soreness, and pressure that intermittently radiates down his left leg. Symptom aggravators included prolonged walking, standing, sitting, or lifting greater than 30 pounds. Additionally, he reported the inability to march, run, jump, rucksack, perform sit ups/pushups, carry heavy objects, wear Kevlar, or perform field training exercises. His physical examination (PE) revealed paraspinal lumbar tenderness with left leg radiation upon straight leg raising. Thoracolumbar range-of-motion (ROM) was decreased and painful. His diagnosis remained as chronic LBP.

At the VA Compensation and Pension (C&P) examination on 6 January 2005 (2 months after separation) the CI endorsed the inability to perform duties of a “maintenance helper” which included, “lifting, bending, and crawling on the ground and working under vehicles.” His PE revealed midline lumbosacral tenderness, decreased and painful motion of the thoracolumbar spine. An antalgic gait was present. “Sensation is intact to monofilament testing from the thighs through the legs to the toes bilaterally.” His diagnosis was listed as myofascial pain syndrome, lumbar spine. 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 ~8 Mo. Pre-Sep
VA C&P ~2 Mo. Post-Sep
Flexion (90 Normal)
 90 70
Combined (240)
 215 190
Comment
 painful motion painful motion ; antalgic gait; tenderness
§4.71a Rating
 10 % 20 %

The Board directed its attention to its rating recommendation based on the above evidence. Although the PEB and VA titled the unfitting back condition slightly differently, they both utilized (in various combinations) similar impairment codes of 5237 (lumbosacral strain) and 5236-5237 (sacroiliac injury and weakness and lumbosacral strain) both rating the back condition 10%. Board members first agreed that sufficient evidence of painful motion as well as the combined ROM was present to justify the PEB’s 10% rating IAW VASRD §4.71a. The Board then deliberated on examination probative value and agreed that a higher degree of probative value be assigned to the VA examination due to its nearer time reference to separation. Board majority agreed that the evidence of tenderness, coupled with an antalgic gait supported the 20% impairment level. Board members also concluded that there was no examination in evidence on which to base a conclusion that repetitive motion resulted in any additional disability. There also was no evidence of a ratable neurologic impairment or documentation of incapacitating episodes in this case which would provide for additional or higher rating. Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a final disability rating of 20% for the low 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 low back condition and IAW VASRD §4.71a, the Board by a majority vote recommends a 20% disability rating, coded 5237. 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
Chronic Low Back Pain 5237 20%
RATING
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131213, 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 XXXXXXXXXXXXXXX , AR20150014173 (PD201302646)
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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