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AF | PDBR | CY2013 | PD-2013-02730
Original file (PD-2013-02730.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02730
BRANCH OF SERVICE: Army          BOARD DATE: 20140910
SEPARATION DATE: 20061117


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (11B/Infantryman) who was medically separated for chronic low back pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) and unable to satisfy physical fitness standards. His was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). No other conditions were submitted by the MEB. The chronic low back pain was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated the chronic low back condition as unfitting and rated 10%. The CI made no appeals and was medically separated.


CI CONTENTION: “The back injury I received while training for combat continues to negatively affect my living situation. The VA itself has rated me as 50% disabled. Cont…..”


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 chronic low back pain condition is addressed below and, 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 20060626
 VA - (7 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain 5237 10% Strain, Thoracolumbar Spine 5237 10% 20070521
Other x 0 (Not in Scope)
 Other x 6 (Not in Scope) 20070521
Combined: 10%
 Combined: 50%
Derived from VA Rating Decision (VA RD ) dated 2007 0618 ( most proximate to date of separation )


ANALYSIS SUMMARY:

Chronic LBP Condition. The narrative summary (NARSUM) notes the CI had a history of thoracic back pain after “a hard parachute landing” on 24 January 2006. Radiographs of the cervical and thoracic spine were normal. Lumbar spine films showed a transitional lumbosacral vertebrae and mild displacement of L4 on L5, findings not associated with the area of his symptoms. The CI underwent chiropractic treatment, physical therapy and trigger point injections without improvement. Notes in the service treatment record indicated the CI reported frequent daily mid-back muscle spasms, with pain rated at 9/10. Thoracic muscle spasm was specifically noted on during examination on 6 out of 17 treatment notes. The CI was treated with muscle relaxants and Valium (a sedative medication used for refractory muscle spasms) which did not improve his spasms. Thoracic magnetic resonance imaging (MRI) dated 9 June 2006 noted a small protruding disc in the upper thoracic spine and possible a small vertebral fracture. Thoracic CT scan dated 20 June 2006 and a bone scan obtained on 25 July 2006 did not confirm the questioned fracture. The NARSUM electromyography/nerve conduction studies (EMG/NCS) obtained on July 2006, were both negative. The CI was diagnosed by the physical medicine specialist with myofascial pain refractory to treatment.

At the MEB physical medicine addendum dated on 9 August 2006, the CI reported pain between his shoulder blades with intermittent spasms; aggravated by standing, bending, or impact activities and improved by lying on his stomach. He denied numbness or pain of any extremity. On examination, the thoracic spine was normal in appearance. There was tenderness of the thoracic spine, greater on the left and centrally. Straight leg raise (SLR) testing was negative bilaterally. There was no tenderness to palpation (TTP) or with stress of the sacroiliac joints. Lower extremity strength and reflexes were normal. The examiner noted no MRI evidence of thoracic spinal canal encroachment or nerve impingement. At the MEB NARSUM examination performed 2 weeks later, the CI reported mid thoracic back pain. He was noted to be prescribed Valium as needed 3 times per day. The MEB physical exam noted a normal gait with TTP of the thoracic paraspinal muscles. Cervical and thoracolumbar (TL) flexion was “preserved” and “pain as his primary limitation.” Strength, sensation and reflexes of both LE were normal, with bilateral negative SLR testing. Physical therapy ROM was TL flexion of 50 degrees (normal 90 degrees) and TL combined ROM of 152 degrees (normal 240 degrees) with ROM noted to be limited by pain.

At the VA Compensation and Pension (C&P) examination on 21 May 2007 (performed 7 months after separation), the CI reported daily pain of the upper, mid and lower back with stiffness of the upper back, with flare-ups due to activity that’s improved by rest, but denied radiation of the pain, weakness, or sensory disturbances of the extremities. He reported that ROM of the back and neck were additionally functionally limited by muscle spasms and pain during flare-ups a few times per week. The CI reported six or more incapacitating episodes in the past 12 months, with a duration of a day, which required him to “rest.”

The VA exam noted a normal gait, the CI was able to tandem walk and stand on his heels and toes. The examination included the low back and the neck, without specific mention of the thoracic spine. Low back exam noted TTP of the lower lumbar spine, muscles and bilateral sacroiliac joints, without muscle spasm. TL ROM was flexion of 90 degrees and normal combined ROM, with painful motion. The examiner noted additional limitation of motion of the TL spine after repetitive use due to increased pain, with ROM of flexion of 45 degrees and combined ROM of 135 degree. Strength, sensation, reflexes were normal and SLR testing were negative bilaterally. The examination of the neck did not include the thoracic spine. Radiographs of the thoracic spine obtained on 3 May 2007 were normal and noted developmental abnormalities of the lumbar spine not related to the thoracic spine symptoms.

The Board directs attention to its rating recommendation based on the above evidence. The PEB and VA both rated the back condition as code 5237 (lumbosacral strain) at 10%. The VA also rated the neck at 10%, under code under 5237. The evidence in record supports that the CI experienced upper back pain with frequent muscle spasms, which were not well controlled with medication, diagnosed to be related to soft tissue injury. At both the MEB and C&P examinations the CI was noted to have TL ROM of greater than 30 degrees but not greater than 60 degrees, limited by pain and following repetition of ROM at the VA C&P exam. The Board agreed that the CI’s disability due to the back condition met the 20% rating according to VASRD general spine rating guidelines in effect at the time of separation based on ROM, but did not meet the 40% rating, specified as TL flexion of 30 degrees or less. The Board also reviewed to see if a higher evaluation could be achieved by rating intervertebral disc syndrome based on incapacitating episodes. At the VA C&P examination the CI reported incapacitating episodes of a day duration, “six or more” in the last 12 months. However, the VASRD spine rules specify incapacitating episodes as “…requires bed rest prescribed by a physician and requires treatment by a physician” and in the STR there was corroboration of one incapacitating episode of “quarters for 48 hrs.” recorded in the 12 months prior to separation. The Board noted that even if the episodes the CI described were conceded as “incapacitating” due to the noted treatment of “rest,” the CI’s description of frequency would result in a rating of 10% and no higher based on incapacitating episodes and there was no evidence of ratable peripheral nerve impairment that would provide for additional rating. 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 back condition, coded 5237.


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 chronic low back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5237 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 his prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Chronic Low Back Pain 5237 20%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131218, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                 
XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150006486 (PD201302730)


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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