Search Decisions

Decision Text

AF | PDBR | CY2014 | PD-2014-00923
Original file (PD-2014-00923.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-00923
BRANCH OF SERVICE: Army  BOARD DATE: 20140912
SEPARATION DATE: 20091201


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/Infantry) medically separated for low back condition. The low back condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The back condition, characterized by the MEB as “chronic low back pain” (LBP) and “pseudoarthrosis / lumbarization of the S-1 without radiculopathy”, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “lumbosacral strain referred to as low back pain” as an unfitting, rated at 10%, citing criteria of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “Please consider all conditions.”


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 back 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.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board reviews medical records and other available evidence to assess the fairness of PEB rating determinations, using the VASRD standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope consistent with performance-based criteria in evidence at separation.


 RATING COMPARISON :

Service IPEB – Dated 20090929
 VA - (5.5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Lumbosacral Strain/LBP 5237 10% Back Injury 5237 NSC* 20100519
Other x 0 (Not in Scope)
 Other x 9
Combined: 10%
 Combined: 20%
Derived from VA Rating Decision (VARD) dated 20100914 (most proxi mate to date of separation )
 *Condition deferred until VARD dated 20101222 , then condition determined to be not service connected)



ANALYSIS SUMMARY:

Lumbosacral Strain/LBP. The CI was diagnosis with chronic LBP, without any specific injury, in May 2008. The CI described his discomfort as having a stabbing pain that’s primary located on his left side that’s relieved by using heating pads and by stretches. He stated that the repetitive motions such as running, stooping, bending, lifting/wearing/carrying a rucksack and prolonged standing were all triggers of his low back pain. A diagnostic X-ray image revealed a congenital variant with arthritis at S1 and an old compression deformity at T12-L1. His treatment included non-steroidal anti-inflammatory drugs, muscle relaxers, physical therapy and three separate placements of restricted duties. Despite conservative treatments, the CI continued to have constant LBP; therefore he was referred for MEB proceedings.

The narrative summary (prepared 3 months prior to separation) noted the CI described his pain level between an 8 or 9 out of 10 (on a scale 0 to 10; 10 being the worst). He denied complaints of lower extremity numbness or tingling and stated he was without pain while coughing, sneezing or during bowel movements. There was no documentation of changes with the CI’s bowel or bladder functions. The CI had a diagnostic magnetic resonance imaging (obtained 3 months post separation), that revealed a congenital variant of S1 with sclerosis at the right superior sacroiliac joint suggesting arthritis and a remote (old) anterior wedging compression deformity of T12 and L1.

At the VA Compensation and Pension (C&P) examination performed approximately 6 months post separation, the CI reported a history as summarized above. There were no documentations of LBP condition flare-ups.

The goniometric range-of-motion (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) MEB/PT 5.5 Mo s . Pre-Sep VA C&P 5.5 Mo s . Post-Sep
Flexion (90 Normal) 90 90
Combined (240) 240 215
Comment Guarded motion; Tenderness to palpation; Neg. straight leg raise (SLR) ; normal strength, reflexes & sensation Normal gait & posture; No spasm or painful motion; Neg. DeLuca criteria; Neg. SLR; Normal strength, reflexes & sensation
§4.71a Rating 10 % 10 %

The Board directs attention to its rating recommendation based on the above evidence. The PEB applied VASRD code 5237 (lumbosacral or cervical strain) and rated at 10% citing VASRD criteria. The VA also utilized code 5237 and initially deferred service-connection for the back condition requesting further information from the VA’s C&P examiner. The next subsequent VARD dated a year after separation, after receiving the requested information did not grant service connection for the LPB condition citing “no back injury was found upon VA examination. Therefore, no permanent residual or chronic disability subject to service connection is shown by the service medical records or demonstrated by evidence following service. Service connection for back injury is denied”.

The general rating formula for diseases and injuries of the spine considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease”. The CI had normal thoracolumbar spine ROM documented by physical therapy; however, the post separation C&P examination documented a decreased combined ROM of the thoracolumbar spine. Both of these exams were within 6 months of separation and both met the 10% rating criteria; the physical therapy exam for localized tenderness not resulting in abnormal gait or abnormal spinal contour and the VA’s C&P for decreased combined ROM. There is no evidence based coding/rating scheme that would result in a disability rating greater than 10% in this case. Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the chronic low back pain was appropriately recommended in this case; therefore, this condition could not be recommended for additional disability rating.


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 lumbosacral strain/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 recharacterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140522, 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, AR20150006244 (PD201400923)


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

Similar Decisions

  • AF | PDBR | CY2014 | PD-2014-01040

    Original file (PD-2014-01040.rtf) Auto-classification: Approved

    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 PT performed ROMs for the MEB exam and noted an abnormal spine motion. 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.

  • AF | PDBR | CY2013 | PD-2013-02646

    Original file (PD-2013-02646.rtf) Auto-classification: Approved

    Post-Separation) ConditionCodeRatingConditionCodeRatingExam Chronic Low Back Pain…5299-523710%Myofascial Pain Syndrome, Lumbar 5236-5237Deferred→ 10%20050106Other MEB/PEB Conditions x 0 (Not In Scope)Other x 13 RATING: 10%RATING: 50% → 70% *Derived from VA Rating Decisions (VARD)dated 20050511 and 20050623(most proximate to date of separation (DOS)). Post-SepFlexion (90 Normal) 90 70 Combined (240)215190 Comment painful motion painful motion ; antalgic gait; tenderness §4.71a...

  • AF | PDBR | CY2013 | PD-2013-01214

    Original file (PD-2013-01214.rtf) Auto-classification: Denied

    A physical therapy note, the next day 26 March 2004 found range-of-motion (ROM) of 75 degrees flexion and 30 degrees of extension. RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation: Physical Disability Board of Review

  • AF | PDBR | CY2013 | PD-2013-02730

    Original file (PD-2013-02730.rtf) Auto-classification: Approved

    Post-Separation) ConditionCodeRatingConditionCodeRatingExam Chronic Low Back Pain523710%Strain, Thoracolumbar Spine523710%20070521Other x0 (Not in Scope)Other x 6(Not in Scope)20070521 Combined: 10%Combined:50%Derived from VA Rating Decision (VARD)dated 20070618 ( most proximate to date of separation) Chronic LBP Condition . 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...

  • AF | PDBR | CY2013 | PD-2013-01253

    Original file (PD-2013-01253.rtf) Auto-classification: Approved

    Two weeks later, he was medically evaluated and given a muscle relaxant medication, which improved his symptoms. The Board considered the MEB NARSUM to be the most probative for a rating at the time of separation because it was the most proximate to the date of separation, and consistent withthe onset of pain limitations from the VA C&P examination and the MEB physical examination. The MEB physical exam on 12 July 2004, 4 months prior to separation, noted decreased and painful cervical...

  • AF | PDBR | CY2013 | PD-2013-02651

    Original file (PD-2013-02651.rtf) Auto-classification: Denied

    The Informal PEB adjudicated “chronic thoracolumbar back pain due to scoliosis” as unfitting, rated 20%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). 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. RECOMMENDATION : The Board,...

  • AF | PDBR | CY2013 | PD-2013-02265

    Original file (PD-2013-02265.rtf) Auto-classification: Denied

    SEPARATION DATE: 20040831 Pre-Separation) ConditionCodeRatingConditionCodeRatingExam Discogenic Low Back Pain523710%Thoracolumbar Spine Strain523710%20040628L4/L5 HNPCategory 2No VA EntryOther x 0 (Not is Scope)Other x 11 Rating: 10%Combined: 30%Derived from VA Rating Decision (VARD)dated 20041013 ( most proximate to date of separation) ANALYSIS SUMMARY :IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. At the MEB...

  • AF | PDBR | CY2013 | PD-2013-01641

    Original file (PD-2013-01641.rtf) Auto-classification: Approved

    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 reviewed both exams present for review to arrive at its rating recommendation. BOARD FINDINGS : IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB...

  • AF | PDBR | CY2014 | PD-2014-00037

    Original file (PD-2014-00037.rtf) Auto-classification: Approved

    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. The VA exam was closest to the date of separation and documented worsened pain-limited ROM than the MEB exam. 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.

  • AF | PDBR | CY2013 | PD-2013-01837

    Original file (PD-2013-01837.rtf) Auto-classification: Denied

    RATING COMPARISON : Service IPEB – Dated 20040610VA -(STR) ConditionCodeRatingConditionCodeRatingExam Chronic Low Back Pain without Neurologic Abnormality5299-523710%Degenerative Disc Disease of the Lumbar Spine at L5 (claimed as chronic low back pain)524210%STROther x 0Other x 1 Rating: 10%Combined Rating: 10%Derived from VA Rating Decision (VARD)dated 20041026 ( most proximate to date of separation [DOS]). BOARD FINDINGS : IAW DoDI 6040.44, provisions of DoD or Military Department...