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AF | PDBR | CY2014 | PD-2014-02043

Original file (PD-2014-02043.rtf) Auto-classification: Approved

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX CASE: PD-2014-02043
BRANCH OF SERVICE: Army BOARD DATE: 20150213

SEPARATION DATE: 20071127

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Motor Transport Operator) medically separated for a chronic low back condition. The 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 condition characterized as “chronic low back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “lumbosacral strain” as unfitting, rated 10%. 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 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 20071012	VA - (2 Mos. Post-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Lumbosacral Strain	5237	10%	Chronic Lumbosacral Mechanical Strain/Pain	5237	10%	20080128
Other x 0 (Not in Scope)	Other x 10 (Not in Scope)	20080128
Combined: 10%	Combined: 40%

Derived from VA Rating Decision (VA RD ) dated 20080512 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY:

Low Back Pain Condition. Review of the service treatment record showed a history of chronic low back pain initiated by heavy lifting in approximately 2003. Worsening in 2006 and 2007 led to increased difficulty in accomplishing job requirements. Radiating pain and lower extremity numbness was evaluated with magnetic resonance imaging which showed lower lumbar degenerative disc disease with disc herniation at L4-5 and L5-S1. A surgical option was not advised. Treatment with physical therapy, steroid injections and pain medication did not result in sufficient improvement. On 18 September 2007 (2 months prior to separation), a physical therapy (PT) examiner provided documentation of thoracolumbar range-of-motion (ROM) measured with an inclinometer. Forward flexion was 10 degrees (normal 90 degrees) and combined ROM was 105 degrees (normal 240 degrees). Painful, limited motion was noted, but there was no localized tenderness, muscle spasms or guarding. Gait and spinal contour were normal. The narrative summary prepared on 24 September 2007 reported a complaint of occasional radiating pain to the left heel, but weakness was denied. Examination showed a normal gait and mild lumbar tenderness. Spinal contour was normal, but posture was “slightly abnormal, flexed forward at the lumbosacral spine region.” Lower extremity muscle strength was normal. An examination the following day recorded some muscle spasm of the lower back, and a gait that was “normal however shuffling due to pain.” Thoracolumbar spine motion was normal, although measurements were not provided. The CI was sent home on quarters for 72 hours for bed rest. At follow-up on 29 September 2007, left lumbar muscle spasm was again noted with a left-sided antalgic gait. Thoracolumbar spine motion was normal, but measurements were not provided.

At the VA Compensation and Pension (C&P) exam performed 2 months after separation, the CI reported a pain severity of 7/10 most of the time. Certain movements could cause radiating pain down either lower extremity. He also reported tingling and numbness in both thighs. Examination showed a normal gait, and no limitations on standing or walking, although he did shift his weight frequently due to back pain. Spinal curves were normal. Lower extremity muscle strength was normal. There was no additional loss of motion after repetitive motion. Lumbar flexion was measured at 70 degrees and combined ROM 200 degrees. Tenderness and painful motion were present.

The Board directed attention to its rating recommendation based on the above evidence. The PEB and VA each assigned a 10% rating under the 5237 code (lumbosacral or cervical strain). The Board noted however that the ROM by the PT examiner supported a 40% rating for forward flexion of 30 degrees or less, while the C&P exam justified a 10% rating for flexion greater than 60 degrees but not greater than 85 degrees. In assigning probative value to these examinations, the Board noted that: (1) the PT exam relied on an inclinometer to measure lumbar motions, which provides numbers that do not correlate with the goniometric normal values reflected in the VASRD; (2) there was a documented absence by the PT examiner of findings which would be expected in association with the dramatically reduced flexion, such as muscle spasm, guarding, abnormal gait or altered spinal contour; and (3) concurrent outpatient notes reported normal, though unmeasured, ROM. Board members therefore assigned preponderant probative value to the VA C&P evaluation which supported a 10% rating on the basis of ROM. In considering other pathways to a higher rating, it was noted that some outpatient evaluations during the time leading up to separation reported the presence of muscle spasm that was associated with an abnormal gait, although this was an inconsistent finding. The Board concluded that this was a sufficient basis for a 20% rating (i.e. for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis). The Board also deliberated whether a higher rating could be achieved under the formula for rating intervertebral disc disease based on incapacitating episodes. During the year prior to separation there was evidence of physician prescribed bed rest for less than a week, which did not meet the minimum rating under that formula. The Board finally considered if additional disability was justified for a history of lower extremity radiculopathy. The CI complained of intermittent radiating pain to the lower extremities. However, the CI denied muscle weakness, and examinations recorded normal muscle strength. The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting. There is no evidence in this case of functional impairment attributable to peripheral neuropathy. While the CI experienced some radiating pain, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” The Board therefore concludes that additional disability was not justified on this basis. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the lumbosacral strain 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. In the matter of the lumbosacral strain condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING
Lumbosacral Strain	5237	20%
COMBINED	20%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140509, 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, AR20150010466 (PD201402043)

1. 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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final.

2. 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.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

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-2014-02043

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