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AF | PDBR | CY2014 | PD-2014-02109
Original file (PD-2014-02109.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2014-02109
BRANCH OF SERVICE: Army  BOARD DATE: 20150225
SEPARATION DATE: 20081006


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Combat Engineer) medically separated for chronic lower back pain. 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 L3S1 profile and referred for a Medical Evaluation Board (MEB). There was no MEB document in evidence but the narrative summary (NARSUM) listed thoracic spondylosis and myofascial pain syndrome as the two diagnoses. A third condition, as noted on the psychological evaluation listed adjustment disorder with mixed disturbance of emotions (medically acceptable), and was forwarded to the PEB for adjudication IAW AR 40-501. The Informal PEB was not available in evidence but the Formal PEB (FPEB) adjudicated chronic thoracolumbar back pain with myofascial pain syndrome that could not be separately rated due to overlap of symptoms as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). T he remaining condition was determined to be “not compensable although possibly administratively unfitting . ” The CI non-concurred with the FPEB, but did not submit a rebuttal and was medically separated.


CI CONTENTION: “Percentage assigned at the time of discharge may have been incorrect.”


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 :

Service FPEB – Dated 20080730
 VA - (8 Mos. Pre -Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Thoracolumbar (TL) Back Pain 5299-5237 10% Lumbar Strain 5237 10% 20080219
Myofascial Pain Syndrome No VA Entry
Other x 1 (Not in Scope)
 Other x 5
Rating: 10%
 Combined Rating: 40%
Derived from VA Rating Decision (VA RD ) dated 200 90406 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY:

Chronic Back Pain Condition. Review of the service treatment record showed an initial visit for back pain in November 2006, at which time the CI complained of a 3-month history of low back pain that began while deployed to Iraq. The CI denied any traumatic injury. He was seen multiple times over the next several months for middle and lower back pain that did not respond well to medication, physical therapy or chiropractic care. A pain specialist opined that thoracic and lumbar spondylosis and myofascial pain were the causes of the back pain, although imaging studies of the thoracic spine were normal. Radiofrequency ablation at lumbar and thoracic levels did not provide sufficient pain relief.

At the NARSUM evaluation on 26 December 2007 (9 months prior to separation) the CI reported that his back problem began as a consequence of improvised explosive device explosions. He continued to experience pain in the lower thoracic region of the spine that was aggravated by any lifting, carrying, running, pushing, pulling or walking over rough terrain. Physical examination noted an appearance of being in pain, although he could bend forward and remove and replace his shoes with minimal apparent discomfort. Gait and spinal curvatures were normal. Lower thoracic spine tenderness and muscle spasm were present. The examiner stated that there was limitation of motion. Although the examiner referred to “appended” goniometric range-of-motion (ROM) measurements, they were not in evidence. The NARSUM cited the pain specialist who opined that the CI’s back disability was accounted for by thoracic spondylosis and myofascial pain syndrome.

At the VA Compensation and Pension exam performed 8 months prior to separation, the CI reported pain in the upper right back radiating to the lower back. Medication provided partial relief of symptoms. He did not use a brace or assistive device for walking. He avoided high impact or contact sports due to his condition. Examination showed normal spinal contour and gait. Tenderness of the thoracic and lumbar spine was present, but muscle spasm was absent. Lumbar flexion (after three repetitions) was 70 degrees (normal to 90 degrees) and combined ROM was 205 degrees (normal 240 degrees).

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under an analogous 5237 code (lumbosacral strain). Board members acknowledged the diagnosis of myofascial pain syndrome, but agreed with the PEB that any associated disability could not be separately rated, and was properly subsumed under the 5237 code. The VA made no such diagnostic distinctions, and also rated lumbar strain at 10% under the same code. The available limitation of motion in evidence supported a 10% rating, but no higher, for flexion greater than 60 degrees but not greater than 85 degrees. Spine tenderness, the rating rationale cited by the PEB, also supported a 10% rating. Although muscle spasm was reported, there was no requisite link to abnormal gait or spinal contour, and therefore a 20% rating was not warranted on this basis. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was 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 thoracolumbar 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 20140327, 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 XXXXXXXXXXXXXXXXXXXX , AR20150013733 (PD201402109)

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                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA



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