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AF | PDBR | CY2014 | PD-2014-00558
Original file (PD-2014-00558.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-00558
BRANCH OF SERVICE: Army  BOARD DATE: 20141114
SEPARATION DATE: 20041021


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (21J10/General Construction Equipment Operator) medically separated for low back pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The low back condition, characterized as “mechanical low back pain, radicular, lumbosacral” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic non-radiating low back pain with insidious onset” as unfitting, rated at 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “New medical evidence from the VA will show that my condition was much worse than what was diagnosed. I have shooting pain and weakness in my legs as well as low range of motion.”


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 low back condition is addressed below and no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any condition 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.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veteran Affairs, operating under a different set of laws. The Board considers VA evidence proximate to separation in arriving at its recommendations and DoDI 6040.44 defines a 12 months interval for special consideration to post-separation evidence. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.






RATING COMPARISON :
Service IPEB – Dated 20040916
 VA* - (~6 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Non-radiating Low Back Pain 5299-5237 10% Degenerative Disc Disease L-Spine 5242-5243 10% 20050408
Intermittent Radiculopathy, Rt Lower Extremity assoc w/ DDD L-spine 7399-7346 0% 20050408
Other x # (Not in Scope)
 Other x 3
Rating: 10%
 Combined: 10%
* Derived from VA Rating Decision (VA RD ) dated 200 50517 (most proximate to date of separation )


ANALYSIS SUMMARY:

Low Back Condition. The narrative summary (NARSUM) notes the CI developed low back pain of “conflicting etiology” described as both a fall striking his lower back (tail-bone) and onset of pain while lifting a tire in early 2002. Initial routine X-ray images of the back were negative. On exam obtained on 21 June 2002, the range-of-motion (ROM) evaluation of the back was flexion of 100 degrees, extension of 40 degrees with mild pain (normal, 90 degrees and 30 degrees respectively). Sensory examination revealed no evidence of peripheral neuropathy or spinal cord injury (groin “saddle anesthesia”).

In September and October 2002, the CI reported the onset of new sexual dysfunction, inability to maintain an erection greater than five minutes, during a neurologic examination. The examiner, noted no evidence of motor or sensory difficulty, no motor weakness or “groin saddle anesthesia” was present at this time. A magnetic resonance imaging (MRI) of the back, obtained in November 2002, revealed broad based disc bulges in the lower spine without compression of the spinal nerves and no injury to the spinal cord. On physical therapy evaluation (PT) obtained on 17 December 2002, ROM of the lower back was normal. On evaluation in January 2003, the CI denied any bowel or bladder problems, numbness in the groin area or leg weakness and made no mention of sexual dysfunction.

On a neurosurgical evaluation 20 February 2003, the CI reported no bowel or bladder dysfunction. On examination motor, sensory, reflex and tests for spinal cord injury were normal. The neurosurgeon opined the CI to have “chronic low back pain without neuropathy” and “his problem is probably multifactorial partially related to his weight and conditioning”. No surgery was recommended. On 30 March 2003, the CI was evaluated in the emergency department for low back pain with reports of two episodes of urinary incontinence and one episode of fecal incontinence. Neurologic exam was normal and the examiner assigned 4+/5 Waddell signs (signs of disingenuousness) to the encounter. From this time until the NARSUM examination, the service treatment record of multiple clinic visits contained no further references of bowel, bladder or sexual dysfunctions. On a post deployment health assessment April 2004, the CI reported his health to be “good” with his only expressed health concern a “rash on his shoulder”.

On the MEB’s questionnaire and at the MEB’s history and physical form (DD Form 2808) completed on 10 August 2004, the CI made no reports of bowel or bladder problems. The neurologic examination was recorded as normal. At the MEB NARSUM evaluation 
26 August 2004 (2 months prior to separation), the physical examination was omitted. ROM findings of the physical therapy examination dated 20 August 2004 were spinal flexion of 75 degrees, extension of 8 degrees and combined ROM of 200 degrees with painful motion.

At the VA Compensation and Pension (C&P) exam (performed 6 months after separation), the CI reported no bowel or bladder problems. He no reports of incapacitation for the condition but reported flare-ups of back pain “every few months” often brought on by “sitting in a fishing boat all day”. The examiner reported the CI to demonstrate no evidence of pain throughout his exam. On physical examination the gait was normal. The CI was able to lie down on the examination table and rise without difficulty and flex without pain from lying to sitting on the table. On ROM evaluation, the CI declined to flex his back more than 30 degrees, achieved without pain, stating that to do so “might give him back problems”. Motor, sensory and reflex examinations were normal and no back spasm was present.

The Board directs attention to its rating recommendation based on the above evidence. The PEB and VA both rated the back condition at 10% for painful motion IAW §4.71a and §4.59 using different codes. The PEB used code 5237 (lumbosacral strain) and the VA used code 5243, (intervertebral disc syndrome). Under both codes, a higher rating of 20% requires flexion of thoracolumbar spine greater than 30 degrees, but less than 60 degrees or the combined ROM of the thoracolumbar spine not greater than 120 degrees. The Board unanimously agreed that the record supported a 10% rating for the back condition for painful motion.

The Board noted the reduced flexion to 30 degrees on the VA C&P evaluation. The Board gave lower probative to this exam as the finding was internally inconsistent with the remainder of the back exam. The Board unanimously agreed that the record in evidence did support a compensable rating for the back condition of 10%, but no higher using ROM criteria. The Board then considered other avenues for appropriate rating.

The Board noted the occasional reports of bowel, bladder incontinence, sexual dysfunction and considered a rating for spinal cord injury IAW §4.115 (Diseases of the Genito-urinary system) and §4.114 (Diseases of the digestive system) The Board agreed that the preponderance of evidence in record, to include multiple negative neurologic examinations by physical therapy, a neurosurgical evaluation, a normal MRI study and the absence of symptoms proximate to separation, did not support a defined bowel, bladder or sexual dysfunction related to the back condition at the time of separation. The Board concluded that no additional rating could be recommended. There was no evidence of a peripheral nerve impairment in this case, since no motor weakness was present, neurologic exams were normal and sensory symptoms had no functional implication. There was no evidence of incapacitating episodes for a higher rating under code 5243. The Board found no other appropriate codes for consideration and no pathway to a rating higher than 10% for the back condition. After due deliberation, considering the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back 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. 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 back 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, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.








The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140121, 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, AR20150007059 (PD201400558)


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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