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AF | PDBR | CY2014 | PD-2014-00213
Original file (PD-2014-00213.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX        CASE: PD -2014 -00213
BRANCH OF SERVICE: Army   BOARD DATE: 201 5 0615
Separation Date: 20061019


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) wa s an active duty E-2 ( Diver Trainee) medically separated for a back condition. The condition could not be adequately rehabilitated to meet the physical requirements of his M ilitary Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “chronic low back pain, herniated nucleus pulposus at L5-S1 with radiculopathy” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The I nformal PEB adjudicated “chronic low back pain ( LBP) ” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeal s and was medically separated.


CI CONTENTION : “Due to the radiopathy of my left and right lower extremities has affected everything. I have problems walking, sitting, standing, lifting, sharp pains down both my legs daily. Has also lead to major depression as have trouble walking or they will not hire me because I’m really injured.”


 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 20061004
 VA* - (~3 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic LBP 5237 10% Lumbosacral Intervertebral Disc Syndrome 5243 10% 20070227
S1 Radiculopathy Left Lower Extremity 5243-8520 10% 20070227
Other x 0 (Not In Scope)
 Other x 0
RATING: 10%
 RATING: 20%
*Derived from VA Rating Decision (VARD) dated 20070618 (most proxi mate to date of separation [DOS] ).

ANALYSIS SUMMARY :

 Chronic LBP Condition . The CI sustained and injury to his lower back during Basic T raining in April 2006 . At that time h e reported symptoms of lower back stiffness and numbness to the first and second toes on both feet. A lumbar spine X- ray showed finding s consistent with post-traumatic changes ( bilateral defects at L5 ) . A lumbar spine magnetic resonance imaging showed a left lumbosacral (L5-S1) herniated disc which moderately compressed the left first sacral (S1) nerve root ( narrowing of the neural foramina) . He continued to report LBP and radicular symptoms with physical exam ination find in gs of lumbosacral spine pain ful motion and occasional muscle spasm s . The CI was evaluated by physical therapy with physical exam findings of pain with range - of - motion (ROM) , abnormal spine motion; positive radiculopathy testing ( straight leg raising [ SLR ]) on the left to 35 degrees ; and decreased sensation to light touch. The Orthopedist noted physical exam findings of lumbosacral spine tenderness to palpation of the spinous process, and positive SLR at 45 degrees. The Neurologist noted constant back and leg pain, stiffness, muscle weakness , and muscle aches. The examiner diagnosed L5-S1 herniated disc with a radiculopathy. There were physical exam findings of SLR to 80 degrees, normal motor strength, S1 sensory loss on the left , and an absent S1 reflex on the left. PT ROMs used for the MEB exam are noted in the chart below. The MEB narrative summary (NARSUM) exam a month prior to separation documented continued reports of LBP that radiated down both lower extremities to his heels ; mostly on the left and constant numbness. The pain was aggravated by prolonged standing, walking, any strenuous physical activities, wearing military gear around the waist, and lifting more than 10 pounds. The MEB NARSUM physical exam findings are summarized in the chart below. The CI was given a permanent L3 profile for LBP with additional Code C and V restrictions. The VA Compensation and Pension (C&P) exam approximately 4 months after separation documented report s of stiffness and difficulty bending / moving with constant pain that radiated to the left leg. The pain was elicited by physical activity and relieved by medication and rest. The CI reported that his LBP did not cause incapacitation. The VA C&P physical exam findings are summarized in th e chart below.

There were ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.


Thoracolumbar ROM
(Degrees)
 PT ~2 Mo. Pre-Sep
 MEB ~ 1 Mo.Pre-Sep
 VA C&P ~ 4 Mo. Post-Sep
Flexion (90 Normal)
 90 90 70 *
Extension (30)
 15 15 20 15*
Combined (240)
 225 225 190/185
Comment
 Fully transfer from supine-sit-stand with minor discomfort due to lumbar stiffness; motor 5/5; sensory intact; no Waddell’s; ROM limited by pain at end range of extension/right lateral flexion and left rotation; all discomfort from left paravertebral muscles L3-5 region only Loss of spinal rhythm; nml gait; straight leg raising (SLR) 70 degrees bilat; motor 5/5 bilat; sensory decreased at L5(great toe) on left; reflexes nml; localized tenderness L3-L5; no Waddell’s Gait stilted; * pain occurs; radiating pain with movement; muscle spasm; flattening of paraspinal muscles; tenderness to palpation the paraspinous muscles; + SLR left; additionally limited by pain, fatigue, lack of endurance, pain has major functional impact; additionally limited joint function by 5 degrees
§4.71a Rating
 10 % 10% 10 %
invalid font number 31502
The Board direct ed attenti on to its rating recommendation based on the above evidence . The PEB coded the c hronic LBP condition as 5237 ( Lumbosacral strain ) and rated at 10%. The VA coded the l umbosacral i ntervertebral d isc s yndrome rated at 10%, coded as 5243 ( Intervertebral disc syndrome ) . The Board determined that evidence of localized tenderness not resulting in abnormal gait or abnormal spinal contour met the 10% rating criteria. The Board determined the evidence did not support a higher than 10% rating. The Board then considered whether the left lower extremity radiculopathy rose to the level of unfitting. Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation. The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a. The sensory component in this case ha d no functional implications. There was no motor impairment that c ould be linked to significant physical impairment. The Board determined that the evidence did not support an unfitting radiculopathy; therefore , no additional rating based on peripheral nerve impairment could be recommended. 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 c hronic LBP condition without the addition of a peripheral neuropathy.


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 c hronic LBP 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, 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 20 131216 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review




invalid font number 31502



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 , AR20150015583 (PD201400213)

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

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