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AF | PDBR | CY2014 | PD-2014-00030
Original file (PD-2014-00030.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2014-00030
BRANCH OF SERVICE: Army  BOARD DATE: 20140822
SEPARATION DATE: 20070510


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (15T/Blackhawk Crew Chief) medically separated for back and right wrist problems. The back and wrist conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty; however, he was able to do an alternate physical fitness test. He was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). The back and wrist conditions, characterized as “chronic low back pains status post (s/p) lumbar fusion and instrumentation with strut graft” and “chronic right wrist pain s/p open reduction and internal fixation (ORIF) of the right distal radius fracture,” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “chronic back pain, s/p lumbar fusion, w/o neurologic abnormality” and “chronic right wrist pain, s/p operative fixation of fracture” as unfitting, rated 0% and 0% respectively, citing the US Army Physical Disability Agency (USAPDA) pain policy for the wrist and the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: The CI elaborated no specific contention in his application.


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 ratings for the unfitting back and right wrist conditions are 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.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.


RATING COMPARISON :

Service IPEB – Dated 20070212
 VA - (5 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam

Chronic Back Pain, S/P Lumbar Fusion, W/O Neurologic Abnormality
 5241 0% Status Postoperative Fusion Burst Fractures, Lumbar Spine 5242 20% 20061213
Lumbar Radiculopathy, RLE 8699-8620 10% 20061213
Chronic Right Wrist Pain, S/P Operative Fixation of Fracture 5099-5003 0% Status Postoperative Open Reduction Internal Fixation Radius Fracture, Right Wrist 5215 0% 20061213
Other x 0 (Not in Scope)
 Other x 5 20061213
Combined: 0%
 Combined: 50%
Derived from VA Rating Decision (VA RD ) dated 200 70724 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Chronic Back Pain Condition. The CI sustained a lumbar spine injury in December 2005 from a 30 foot fall while deployed to Iraq. Compression fractures of the L4 and L5 vertebrae required surgical fusion of L2 through S1, followed by bone grafting. As a consequence of initial surgical screw positioning, a post-operative right lower extremity radiculopathy developed, characterized by numbness and muscle weakness. The screw position was modified and neurologic symptoms ultimately improved. Despite ongoing treatment with physical therapy and medication, he continued to experience activity-limiting pain.

At the narrative summary (NARSUM) examination on 13 December 2007 (5 months prior to separation) the CI reported no pain at rest. Pain occurred with lifting greater than 20 pounds, running greater than 1/2 block or any bending activities. He reported difficulty climbing, carrying heavy items or playing sports. Physical exam noted no tenderness. X-rays of the lumbar spine noted intact surgical hardware and degenerative changes.

At the VA Compensation and Pension (C&P) exam on 13 December 2007, the CI reported low back pain that was aggravated by prolonged standing or changes in weather and alleviated by medication and application of heat. Daily flare-ups lasted 15 minutes. Examination showed a normal gait, non-tender spine and no muscle spasm; guarding and spinal contour was not mentioned. There was no change in range-of-motion (ROM) with repetitive motion.

The physical therapy examiner on 5 February 2007 (3 months prior to separation) reported a normal gait and no muscle spasm. Guarding was present, but the observed abnormal spinal contour was stated to be due to surgery. 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)
 VA C&P ~5 Mo s . Pre-Sep PT ~3 Mos. Pre-Sep
Flexion (90 Normal)
 45 45 (45, 45, 45)*
Extension (30)
 10 10 (10, 10, 10)*
Combined (240)
 145 135
Comment
 +Guarding
§4.71a Rating
 20% 20%
     *M easurements taken w ith inclinometer placed at T12-L1.

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating under the 5241 code (spinal fusion), while the VA rated the condition at 20% under the 5242 code (degenerative arthritis of the spine). The different coding choices did not bear on rating. The Board agreed that both of the ROM examinations reported lumbar flexion that justified a 20% rating (i.e. forward flexion greater than 30 degrees but not greater than 60 degrees). Under the general spine formula, criteria for a 40% rating were not present. The Board also considered rating intervertebral disc disease under the alternative formula for incapacitating episodes, but could not find sufficient evidence which would meet a minimal rating under that formula. 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.

Chronic Right Wrist Pain Condition. During the same incident that caused the spine injury, the right hand dominant CI also sustained a fracture of the right wrist that required ORIF of the distal radius. He continued to experience pain despite rehabilitative treatment. On the Report of Medical Assessment dated 13 November 2006 (6 months prior to separation), the CI indicated that only the lumbar spine condition interfered with performance of his duty. The NARSUM reported wrist pain with carrying more than 10 pounds, twisting or grasping. He could not do push-ups or pull-ups. Examination showed no bone or joint tenderness. X-rays of the wrist reported intact surgical hardware and degenerative changes.

At the VA C&P exam the CI reported wrist pain and decreased ROM. Writing and pressure on the wrist precipitated pain, while rest alleviated it. Flare-ups lasted 5 minutes. Examination of the wrist showed a normal appearance and no tenderness. Strength was normal and there was no additional limitation with repetitive motion.

The occupational therapy examiner reported complaints of wrist pain with weight-bearing and use, such as wrenching. Wrist motion was non-painful. 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.

Right Wrist ROM
(Degrees)
 VA C&P ~ 5 Mo s . Pre-Sep O T ~ 3 Mo s . Pre-Sep
Dorsiflexion (70 Normal)
 70 60 , 60 , 55
Palmar Flexion (80)
 80 75 , 80 , 75
Ulnar Deviation (45)
 45 25 , 25 , 25
Radial Deviation (20)
 20 20 , 20 , 20
§4.71a Rating
 0% 0% or 10% (PEB 0%) *
            *Conceding functional loss (§4.40) or painful motion (4.59)      

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating under an analogous 5003 code (degenerative arthritis) with application of the USAPDA pain policy, while the VA assigned the same rating under the 5215 code (wrist, limitation of motion of). While compensable limitation of motion was not present on either exam, the Board considered if there was sufficient evidence of functional loss (§4.40) or painful motion (§4.59) to warrant a 10% rating. Board members concluded that exam findings of no tenderness and non-painful ROM did not support this approach and therefore a 10% rating was not justified on this basis. 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 right wrist pain 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. As discussed above, PEB reliance on the USAPDA pain policy for rating chronic right wrist pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5241 IAW VASRD §4.71a. In the matter of the chronic right wrist pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. 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 Back Pain 5241 20%
Chronic Right Wrist Pain 5099-5003 0%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131216, 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, AR20150006494 (PD201400030)
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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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