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AF | PDBR | CY2014 | PD-2014-00477

Original file (PD-2014-00477.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX CASE: PD-2014-00477
BRANCH OF SERVICE: Army BOARD DATE: 20150715

SEPARATION DATE: 20060920

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Multichannel Transmission Operator) medically separated for lumbar spine condition. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS). The profile allowed for an alternate aerobic event to satisfy physical fitness standards. She was issued a permanent P3U3L3 profile and referred for an Medical Evaluation Board (MEB). The “lumbago,” “sacroiliac joint pain,” “left more than right S1 sensory radiculopathies with secondary muscle strains in her lower lumber paraspinal muscles,” “tremors,” and “right cervical sensory radiculopathy, approximately right C7 distribution,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded chondromalacia patellae, left knee for PEB adjudication. The Informal PEB adjudicated chronic radiating low back pain as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.

CI CONTENTION: The CI elaborated no specific contention in her application and lists the conditions which she believes rendered her unfit. Her 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 Veterans Affairs Schedule for Rating Disabilities (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 20060613	VA* - (~5 Mos. Post-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Chronic Radiating Low Back Pain	5237	10%	Chronic Lumbar Strain and Intervertebral Disc	5243	10%	20070216
			Sciatic Nerve…Left…Associated w/ Chronic Lumbar Strain…	8520	10%	20070216
			Sciatic Nerve…Right…Associated w/ Chronic Lumbar Stain…	8520	10%	20070216
Chondromalacia… L Knee	Not Unfitting	Chronic Knee Strain...Left Knee	5260	10%	20070216
		Scar, Left Knee Associated…	8520	10%	20070216
Other MEB/PEB Condition x 2 (Not In Scope)	Other x 4
RATING: 10%	RATING: 60%

* Derived from VA Rating Decision (VA RD ) dated 200 70405 (most proximate to date of separation [ DOS ] )

ANALYSIS SUMMARY:

Chronic Radiating Low Back Pain Condition. Review of the Service treatment record (STR) found that the CI suffered from low back pain since approximately 1998 but experienced acute worsening in April 2005. She subsequently experienced pain, numbness and tingling that radiated down both lower extremities. A computed tomography (CT) scan in May 2005 showed no lumbar disc herniation, and magnetic resonance imaging (MRI) in October 2005 likewise showed no disc herniation, neuroforaminal narrowing or nerve root compromise.

A primary care examiner on 19 September 2005 (a year prior to separation) recorded an episode of low back pain that day. Examination showed a slow, shuffling gait with small steps. Guarding and muscle spasm were not mentioned. Lower extremity muscle strength, sensation and deep tendon reflexes (DTR) were normal. At a chiropractic evaluation on 12 October 2005 the CI reported that back pain was “off and on” and was associated with tingling and numbness of the left posterior thigh, calf and bottom of foot. The right lower extremity was occasionally affected. At a 4 November 2005 visit for a physical exam the CI reported an acute low back pain flare-up with radiation to the left lower extremity that began 20 minutes previously, and she arrived at the appointment in a wheel chair. She had been “fighting these episodes every few days” since April 2005. Examination showed guarding of back movements. She could not bend or transfer to the exam table. At a neurology evaluation in December 2005 (9 months prior to separation) the CI reported extreme pain in the lower back that made walking difficult. Lower back pain occurred 2-3 times per week. Numbness and tingling radiated to the back of the legs and toes. The impression was that a persistent left worse than right S1 sensory radiculopathy was present.

The MEB narrative summary (NARSUM) on 17 January 2006 (8 months prior to separation) reported complaints of difficulty with prolonged walking, any running and inability to lift more than 20 pounds due to back pain. Radiating pain to the lower extremities still occurred, but was improved. Examination showed an antalgic gait and stooped posture. There was no significant spine tenderness, and spasm or guarding was not mentioned. Lower extremity muscle strength, sensation and deep tendon reflexes (DTR) were normal. Range-of-motion (ROM) measurements showed flexion of 80 degrees after 3 repetitions (normal 90 degrees) and combined ROM of 210 degrees (normal 240 degrees).

The CI presented for pain medication refills on 8 February 2006 with complaints of 3 days of low back pain flare-up and left leg pain. She denied leg weakness. She rode her bike to the appointment. Examination showed a “normal” gait that was also characterized by “with slight limp.” The cause of the limp was not identified, but there was no lumbar spasm or tenderness, and painful motion was absent. Muscle strength, sensation and DTR’s were normal.
Follow-up with neurology on 26 February 2006 (7 months prior to separation) recorded low back pain as severe as 8/10, and some days with no pain. She reported that her legs sometimes felt weak. Examination showed “slight distress secondary to low back pain.” Some lower lumbar tenderness was present and gait was non-antalgic but slightly slow. Sensation was slightly but inconsistently decreased on the dorsal and medial left foot. The remainder of the neurologic exam was unchanged from an exam in September 2005, at which time normal muscle strength and DTR’s were noted. The examiner opined that the left worse than right S1 sensory radiculopathy and lumbar condition failed to meet retention standards.

On 13 July 2006 (2 months prior to separation) the CI presented with a flare-up of back pain radiating to the left leg after “stepping wrong.” Exam showed an appearance of discomfort. Lumbar tenderness and painful motion were present. Subtle weakness of the left lower extremity was reported, but affected muscles were not specified.

At the VA Compensation and Pension (C&P) exam on 16 February 2007 (5 months after separation), the CI reported a 2-year history of low back pain. She stated that episodes of pain lasted for 4 days and radiated to the legs. She could not drive, shop, garden, or push a lawn mower because of her back pain. Episodes of incapacitation were denied. Examination showed an antalgic gait, although the source of antalgia was not identified. There was no muscle spasm or spine tenderness, and spinal curves were normal. Thoracolumbar flexion was 80 degrees and combined ROM was 220 degrees. ROM did not change after repetitive motion. Neurologic findings included mild weakness of left hip adduction and abduction; left knee extension and flexion; and left foot extension and plantar flexion. Lower extremity sensation findings were not recorded, and DTR’s were normal. Lumbar spine X-rays showed some straightening of the thoracolumbar junction, but were otherwise normal. A diagnosis of chronic lumbar strain and intervertebral disc syndrome was rendered.

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under the 5237 code (lumbar strain), while the VA also assigned a 10% rating using the 5243 code (intervertebral disc syndrome). The Board agreed that a 10% rating, but no higher, was justified for flexion greater than 60 degrees but not greater than 85 degrees or for combined ROM greater than 120 degrees but not greater than 235 degrees. Board members considered episodes of witnessed abnormal gait, and debated if there was a reliable link to muscle spasm or guarding adequate to support the next higher 20% rating. It was concluded that there was insufficient evidence to warrant this option, and the 20% rating therefore was not justified on this basis. 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 higher rating under that formula.

Finally, the Board considered whether additional rating could be recommended under a peripheral nerve code, as conferred by the VA, for the associated sciatic radiculopathy at separation. The CI complained of pain that radiated to the lower extremities (more often the left), and was variably associated with numbness and tingling. The neurologist rendered a diagnosis of bilateral S1 sensory radiculopathy, and opined that the condition did not meet retention standards. Other examiners noted variable sensation loss or normal sensation, and one provider reported subtle, non-specific left lower extremity weakness; however, all other examiners (including the neurologist) recorded normal muscle strength and DTR’s. The VA examiner reported some rather diffuse but mild left lower extremity muscle weakness; and no other abnormal neurologic findings. It did not appear that the VA examiner was aware of the completely normal lumbar MRI, which rendered the diagnosis of intervertebral disc syndrome untenable. Regardless, the presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend addition of a peripheral nerve rating to disability in spine cases. The pain component of a radiculopathy is subsumed under the general spine rating formula as specified in §4.71a. The sensory component in this case has no functional implications, and true motor impairment (if present) was intermittent and minor. There is thus no evidence of a separately ratable functional impairment (with fitness implications) from the residual radiculopathy; and, the Board cannot support a recommendation for an additional disability rating 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 radiating low back pain condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that a left knee chondromalacia patella was not unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The left knee condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards. This was reviewed and considered by the Board. There was no performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the left knee condition and so no additional disability rating is recommended.

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 radiating low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended left knee chondromalacia patella condition, the Board unanimously recommends no change from the PEB determination as not unfitting. 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 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 XXXXXXXXXXXXXXX, AR20150013431 (PD201400477)

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              XXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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AF | PDBR | CY2014 | PD-2014-00477

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