Search Decisions

Decision Text

AF | PDBR | CY2014 | PD-2014-01433
Original file (PD-2014-01433.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-01433
BRANCH OF SERVICE: Army  BOARD DATE: 20141217
SEPARATION DATE: 20081227


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Transportation Coordinator) medically separated for back pain. The back condition did not improve adequately 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). “Low back pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also forwarded one other condition (depression) for PEB adjudication. The Informal PEB found the back condition unfitting, rated 20%. The depression w as adjudicated as not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: “IAW the Wounded Warrior Act, review of PDBR.”


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 :

Service IPEB – Dated 20080916
 VA – based on Service Treatment Record (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain 5237 20% Lumbosacral Strain 5237 10% STR
Other x 1 (Not In Scope)
 Other x 9
Rating: 20%
 Combined Rating: 40%
Derived from VA Rating Decision (VA RD ) dated 200 90819 ( most proximate to date of separation [ DOS ] )






ANALYSIS SUMMARY:

Back Pain. In February 2007, the CI injured his back in a motor vehicle accident. Magnetic resonance imaging in July 2007 showed mild degenerative disc disease, without spinal stenosis or neuroforaminal narrowing. He was treated with physical therapy and chiropractic measures. His symptoms appeared to improve and he deployed to Iraq. While deployed, he re-injured his back by lifting some heavy boxes. In December 2007, the CI was medically evacuated from Iraq to the US. Due to the chronic, persistent nature of his back pain, a MEB was initiated. The MEB narrative summary was dictated on 16 April 2008. At that exam, gait was normal. The CI exhibited good range-of-motion (ROM) while removing his clothing. There was good muscle strength in the lower extremities and no evidence of any muscle atrophy. Neurological exam was normal. Thoracolumbar ROM was measured and is summarized in the chart below.

On 30 September 2008, the CI was seen for follow-up in the Family Practice clinic. At that exam, gait was normal and no muscle spasm was noted. Straight leg raise was negative. Neurological exam was normal. Thoracolumbar ROM was normal, except for flexion of 45 degrees due to pain. The ROM evaluations which the Board weighed in arriving at its rating recommendation are summarized in the chart below.

Thoracolumbar ROM
(Degrees)		 MEB ~ 8 mos. Pre-Sep
(20080416)
 FPC ~ 3 mos. Pre-Sep
(20080930)
Flexion (90 Normal) 60 45
Combined (240) 160 195
§4.71a Rating 20% 20%
invalid font number 31502
The Board directed attention to its rating recommendation based on the evidence. At each of the back exams noted above, flexion of the thoracolumbar spine was greater than 30 degrees, but not greater than 60 degrees. IAW VASRD §4.71a, a 20% disability rating is warranted when thoracolumbar flexion is greater than 30 degrees but not greater than 60 degrees. Therefore, the Board determined that a 20% rating was appropriate. The Board tried to find a path to a higher rating for the back condition. However, there was insufficient evidence of a significantly disabling back condition that would justify a higher rating.

The Board also considered the matter of peripheral neuropathy. After reviewing all the information in the record, there was insufficient evidence of a clinically significant neuropathy that interfered with performance of military duties. Therefore, the Board concluded that there was no unfitting radiculopathy present at the time of separation. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication for the 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 chronic back pain, 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 20140321, 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, AR20150009556 (PD201401433)


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-2014-02120

    Original file (PD-2014-02120.rtf) Auto-classification: Denied

    “Lumbago”was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.AnInformal PEB (IPEB) adjudicated chronic low back pain(LBP) without neurologic abnormality as unfitting, rated 0%. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVeterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. RECOMMENDATION : The...

  • AF | PDBR | CY2014 | PD-2014-00270

    Original file (PD-2014-00270.rtf) Auto-classification: Denied

    SEPARATION DATE: 20060601 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 directed attention to its rating recommendationbased on the above evidence.The PEB rated the low back condition 10%, coded 5243 (intervertebral disc syndrome) and the VA rated it...

  • AF | PDBR | CY2013 | PD-2013-01439

    Original file (PD-2013-01439.rtf) Auto-classification: Denied

    At the CI’s post-operative visit with his Neurosurgeon, 19 months prior to separation, the CI stated that he “ [did] get occasional lumbar discomfort if he [sat] for prolonged period of time … o/w [the CI was] doing very well.” The neurosurgeon documented that the CI “ [arose] from a chair to a standing position without difficulty.” At a PT evaluation, approximately 16 months prior to separation, the CI stated that his pain level was a “2.5/10” and his “back is doing pretty good but does...

  • AF | PDBR | CY2013 | PD-2013-01831

    Original file (PD-2013-01831.rtf) Auto-classification: Denied

    Thoracolumbar ROM (Degrees)MEB ~ 7½ mos. 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 LBP condition and IAW VASRD §4.71a, the Board...

  • AF | PDBR | CY2014 | PD-2014-00325

    Original file (PD-2014-00325.rtf) Auto-classification: Denied

    RECORD OF PROCEEDINGSPHYSICAL DISABILITY BOARD OF REVIEWNAME: XXXXXXXXXXXXXXX CASE: PD-2014-00325 BRANCH OF SERVICE: AIR FORCE BOARD DATE: 20141031 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. A VA exam performed in December 2008, (over 3 years remote from...

  • AF | PDBR | CY2014 | PD-2014-01628

    Original file (PD-2014-01628.rtf) Auto-classification: Denied

    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. In the matter of the chronic 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...

  • AF | PDBR | CY2014 | PD-2014-00115

    Original file (PD-2014-00115.rtf) Auto-classification: Denied

    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. Under this code, a rating of 20% requires the condition to be “moderate.”The Board noted the significant improvement in ROM findings between the NARSUM and C&P evaluations and presumed this to be related to...

  • AF | PDBR | CY2013 | PD-2013-01774

    Original file (PD-2013-01774.rtf) Auto-classification: Denied

    Post-Separation)*ConditionCodeRatingConditionCodeRatingExam Chronic Back Pain, without Neurological Abnormality5299-523710%Diffuse Lumbar Spondylosis5003-524210%20050104Left L5-S1 Radiculopathy 8599-852010%20050104Other x 0Other x 3 Rating: 10%Combined: 20%Derived from VA Rating Decision (VARD)dated 20050323 ( most proximate to date of separation [DOS]) Low Back Pain (LBP) . A 10% rating is also warranted when combined thoracolumbar ROM is greater than 120 degrees but not greater than 235...

  • AF | PDBR | CY2013 | PD-2013-01560

    Original file (PD-2013-01560.rtf) Auto-classification: Denied

    The condition, characterized as “chronic low back pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The examiner stated, “He could full forward bend, side bend 25 degrees right and left [normal 30], extend 20 degrees [normal 30].” The medical records documented lower extremity peripheral nerve sensory deficits attributed to the CI’s diabetes. Following this exam, as noted above, the VA granted service-connection for the back condition with a 10% rating effective...

  • AF | PDBR | CY2013 | PD-2013-02240

    Original file (PD-2013-02240.rtf) Auto-classification: Approved

    Low Back and Left Leg Pain Condition. Despite additional treatment the CI continued to report primarily back pain with some numbness/tingling to the left thigh area, but was noted to have good strength, sensation and reflexes.A repeat myelogram did not indicate any further nerve compression and no further surgical intervention was recommended.At the MEB examination performed on 9 March 2005, approximately 4 months prior to separation, the CI reported chronic pain increased by activity and...