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AF | PDBR | CY2014 | PD-2014-01999
Original file (PD-2014-01999.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-01999
BRANCH OF SERVICE: Army  BOARD DATE: 20150508
SEPARATION DATE: 20040820


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Infantryman) medically separated for chronic back pain, due to degenerative disk disease, without neurologic abnormality. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “low back pain with degenerative disk disease L4-L5 and L5-S1 with lumbar spondylosis and mild L4/L5 radiculopathy bilateral per EMG and NCS” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated “chronic back pain, due to degenerative disk disease, without neurologic abnormality” as unfitting, rated 20%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “Consider all conditions found unfitting and not unfitting by the physical evaluation board.”


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 20040713
 VA* - (~3 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Back Pain, due to Degenerative Disk Disease, without Neurologic Abnormality 5299-5242 20% Residuals, Lumbar Injury w/Traumatic Arthritis 5010-5237 40% 20040519
Lumbar Radiculopathy, Right Leg (claimed as leg numbness) associated w/Residuals, Lumbar Injury w/Traumatic Arthritis 8520 20% 20040519
Lumbar Radiculopathy, Left Leg (claimed as leg numbness) associated w/Residuals, Lumbar Injury w/Traumatic Arthritis 8520 10% 20040519
Other x 0 (Not In Scope)
 Other x 5
RATING: 20%
 RATING: 70%
* Derived from VA Rating Decision (VA RD ) dated 200 80731 (most proximate to date of separation ( DOS ) )


ANALYSIS SUMMARY:

Chronic Back Pain. In November 2001, this CI injured his back when he was thrown from a vehicle. In 2003, he re-injured his back during a parachute landing fall (PLF). In 2004, he had another PLF that caused back injury. Magnetic resonance imaging of the spine showed degenerative disc disease (DDD). There was mild disc bulging at L4-L5 and L5-S1, but no convincing evidence of disc herniation. Electromyography (EMG) suggested the presence of radiculopathy at both of those levels. It was determined that he was not a surgical candidate. He was treated with physical therapy (PT), back brace, and epidural steroid injections. In spite of all treatment efforts, the back pain persisted and an MEB was initiated. The MEB physical examination (PE) was on 28 June 2004. The CI reported low back pain (LBP), shooting down the right leg, and numbness in both lower extremities. PE of the lower back revealed some tenderness over the lumbar spine. His gait was slightly antalgic. Straight leg raise was negative, and neurological exam was normal. Range-of-motion was measured and is summarized in the chart below. In the MEB narrative summary, the examiner’s diagnosis was: LBP with DDD at L4-L5 and L5-S1, with lumbar spondylosis, and mild L4-L5 radiculopathy bilaterally per EMG and NCS (nerve conduction study).

The CI was medically separated from service on 20 August 2004. In October 2004, 2 months later, he had a VA Compensation and Pension (C&P) exam. He reported that he was working as a technician for an engineering firm. His back pain was occurring daily. The pain was made worse by prolonged standing or prolonged sitting. He was not using any medication at that time. On PE, he walked favoring the left hip and leg. He was not using a cane or other assistive device. Spinal contour was preserved, and there was no muscle spasm which would give an abnormal gait or contour. On neurological exam, the deep tendon reflexes were normal. Sensory testing revealed some decreased sensation bilaterally. Muscle exam of the lower extremities was normal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB and the VA chose different coding and rating options for the LBP condition. At both the June 2004 MEB exam and the October 2004 C&P exam, thoracolumbar forward flexion was greater than 30 degrees but not greater than 60 degrees. IAW VASRD §4.71a, a 20% rating is warranted when thoracolumbar flexion is greater than 30 degrees, but not greater than 60 degrees. A fter a thorough review of the evidence, the Board determined that a disability rating of 20% was appropriate for the LBP condition. The Board tried to find a path to a higher rating, using other codes which could be applied to the LBP condition. The other VASRD codes that were considered did not result in a higher rating, since the treatment record did not show sufficient evidence of a spinal impairment which would justify a higher rating.

The Board also considered the matter of radiculopathy. After review of all the information in the record, there was insufficient evidence of a clinically significant radiculopathy that interfered with performance of military duties. The CI had neurological symptoms, and he was diagnosed with radiculopathy. However, there was no performance-based evidence that the neurological condition significantly interfered with 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 of 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 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 20140429, 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, AR20150013522 (PD201401999)


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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