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AF | PDBR | CY2013 | PD-2013-02681
Original file (PD-2013-02681.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-02681
BRANCH OF SERVICE: Army  BOARD DATE: 20150428
SEPARATION DATE: 20030810


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a drilling National Guard E-5 (Chaplain Assistant) medically separated for back and chest pain. These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent P3L3 profile and referred for a Medical Evaluation Board (MEB). Chronic back pain and atypical chest pain were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic back pain, without neurologic or electrodiagnostic abnormality” and “atypical chest pain” as unfitting, rated 0% and 0%, c iting application of the US Army Physical Disability Agency (USAPDA) pain policy for rating the chest pain and likely application of AR 635-40 for rating the back condition. The CI appealed to the Formal PEB (FPEB) which affirmed the PEB findings and recommendation. The USAPDA issued an Administrative Correction that did not c hange the disposition or rating. The CI made no further appeals and was medically separated.


CI CONTENTION: “At time of discharge I was rated as 0% and all the conditions were not taken into consideration.”


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:

USAPDA ADMIN CORR – Dated 20060508
 VA* - (~18 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Back Pain, w/o Neurologic…Abnormality 5299-5237 0% Spondylolisthesis L4 on L5 5243 20% 20041203
Atypical Chest Pain 5099-5003 0% Residuals, Spontaneous Bilateral Pneumothorax, s/p Left Thoracotomy 6699-6602 0% 20041203
Other x 0 (Not In Scope)
 Other x 0
COMBINED RATING: 0%
 COMBINED RATING: 20%

* Derived from VA Rating Decision (VA RD ) dated 200 50204 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY:

Chronic Back Pain Condition. At the VA exam on 3 December 2004 (18 months prior to separation) the CI reported a 20-year history of low back pain (LBP). Although pain occurred “constantly” it was noted to be “elicited by physical activity” and “relieved by rest.” He noted pain that radiated to the legs. Examination showed a normal posture and gait. Spinal tenderness and spasm were not present. Range-of-motion (ROM) measurements showed flexion of 60 degrees (normal 90 degrees) and combined ROM of 200 degrees (normal 240 degrees). Neurologic findings (including muscle strength) of the lower extremities were normal.

At an evaluation by physical therapy (PT) on 6 January 2006 (5 months prior to separation) the CI reported a current LBP severity of 8/10, although the average was 3/10. Symptoms of radiculopathy were denied. ROM measurements were obtained with an inclinometer, and showed flexion of 60 degrees (normal 90 degrees) and combined ROM of 170 degrees (normal 240 degrees). Painful motion was present in all directions. Gait was normal.

At the MEB exam on 10 January 2006, the CI reported using a back brace but denied impaired use of his legs. Neurologic examination was normal. The narrative summary (NARSUM) noted that LBP was aggravated by prolonged sitting and standing, and improved with rest and swimming. Physical examination on 20 January 2006 showed normal gait and stance. Magnetic resonance imaging showed degenerative disc disease with moderate disc bulging at L4-5 causing moderate to severe right-sided neuroforaminal impingement and mild to moderate left-sided impingement.

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating coded analogously to 5237 (lumbar strain), while the VA rated the condition at 20% using the 5243 code (intervertebral disc syndrome). The Board considered that the ROM in evidence suffered some probative value compromise. The VA exam was sufficiently remote as to questionably reflect the condition’s status at the time of separation; and the service PT evaluation relied on an inclinometer, which does not correlate well with values reflected in the VASRD. Board members agreed that a 10% rating was warranted IAW VASRD §4.59 (painful motion), but debated if a higher rating was justified. There was no evidence of muscle spasm or guarding severe enough to cause an abnormal gait or spinal contour, but the next higher 20% rating is also warranted if flexion is greater than 30 degrees but not greater than 60 degrees. Despite probative value concerns regarding the only ROM in evidence, Board members concluded that a 20% rating was supported on the basis of limited flexion. The Board also considered rating intervertebral disc disease under the alternative formula for incapacitating episodes, but could not find sufficient evidence which would support a minimal rating under that formula. Finally, the Board deliberated if additional disability was justified for possible lower extremity radiculopathy. The CI complained of radiating pain to the legs at the VA exam, but denied symptoms of radiculopathy at the service PT evaluation. Examiners recorded normal neurologic findings, including muscle strength. The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting. There is no evidence in this case of functional impairment attributable to peripheral neuropathy. While the CI may have experienced some radiating pain, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” The Board therefore concludes that additional disability was not justified on this basis. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic back pain condition.

Atypical Chest Pain Condition. The CI experienced bilateral spontaneous pneumothoraces (collapsed lungs) in 1986. The right pneumothorax resolved without intervention, but inpatient treatment for chest tube placement was required for the left pneumothorax. In April 1986 several small left apical lung blebs were surgically resected to prevent recurrence of pneumothorax. Review of the service treatment record noted complaints of intermittent chest pain that resolved after approximately 3 years. However, beginning in 2002 he experienced intermittent left sided chest pain. Specialty evaluation concluded that the pain was not due to cardiac or pulmonary problems, but was likely musculoskeletal in origin.

At the VA exam 18 months prior to separation, the CI indicated he experienced chest pain or discomfort with exertion, but that he needed no treatment, experienced no functional impairment, and lost no time from work due to the condition. Examination showed normal lungs and well-healed left axillary scars. A chest X-ray was normal. The examiner’s diagnosis was “spontaneous bilateral pneumothorax status post thoracotomy. (The CI) does not have any complications secondary to his pulmonary disease.”

At the MEB examination, the CI checked “No” for “Asthma or breathing problems related to exercise,” “Shortness of breath,” or “Wheezing or problems with wheezing.” He reported “Pain or pressure in the chest.” The examiner noted “intermittent chest pain with Valsalva” (forceful straining or bearing down). Exam showed a left chest wall surgical scar. The NARSUM noted that chest pain “comes and goes” without any associated coughing or wheezing. Examination showed clear lungs and a non-tender chest.

In a letter dated 13 April 2006 (2 months prior to separation) and used as an exhibit by the FPEB, the CI’s civilian physician wrote: “I believe (the CI) is in excellent physical shape. I would have no problem recommending him to you for any type of duty you are considering.”

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating under an analogous code 5003 (arthritis, degenerative) while the VA also rated the condition at 0%, but under an analogous code 6602 (asthma). There was no VASRD-defined joint range-of-motion to consider for rating this condition, and the Board therefore concluded that the 5003 rating pathway was a poor choice. The 6602 coding option was likewise determined to not accurately reflect the clinical condition. Under an analogous 5321 muscle code (Group XXI, muscles of respiration: thoracic), Board members agreed that “slight” most accurately depicted the condition, and a 0% rating was therefore supported via this pathway. 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 rating for the atypical chest pain condition, but to maintain compliance with the VASRD and IAW §4.73, recommends a 5399-5321 code.
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. As discussed above, PEB reliance on AR 635-40 for rating chronic back pain and the USAPDA pain policy for rating atypical chest pain was operant in this case and the conditions were adjudicated independently of that regulation and policy by this Board. In the matter of the chronic back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5299-5237 IAW VASRD §4.71a. In the matter of the atypical chest pain condition, the Board unanimously recommends no change in the PEB rating of 0%; but stipulates a change of code to 5399-5321 to remain compliant with VASRD §4.73. 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 Back Pain 5299-5237 20%
Atypical Chest Pain 5399-5321 0%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131217, 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 , AR20150012731 (PD201302681)
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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