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AF | PDBR | CY2014 | PD-2014-02348
Original file (PD-2014-02348.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-02348
BRANCH OF SERVICE: Army  BOARD DATE: 20150129
SEPARATION DATE: 20090705


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantryman) medically separated for lower back pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The chronic low back pain (LBP) was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated “L4-5 disc herniation and degenerative disc disease (DDD) of the lower spine,” as unfitting, rated 10%, c iting application of the VA Schedule for Rating Disabilities (VASRD). The CI appealed to the IPEB President, who affirmed the finding and rating and was medically separated.


CI CONTENTION: “Physical conditions continue to deteriorate; 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 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 20090220
 VA* - (~3 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic LBP; L4-5 Disc Herniation and DDD of the Lumbar Spine 5243 10% L3-L4 Disc Bulge w/Facet Hypertrophic Changes; L4-L5 Disc Bulge Midline Disc Herniation; L5-S1 Congenital Smaller Disc 5242 10% 20090415
Other x 0
Other x 7
RATING: 10%
 RATING: 30%
* Derived from VA Rating Decision (VA RD ) dated 20 100106 (most proximate to date of separation ( DOS ) ) .




ANALYSIS SUMMARY:

Lower Back Pain. The CI presented on 16 July 2007 with a 4-month history of LBP after falling down a mountain while deployed. That day, X-rays were abnormal for mild retrolisthesis of S1 (when one vertebra is displaced towards the back over the adjacent vertebrae). He was treated with medications, but his symptoms persisted. He was treated with physical therapy without resolution and referred to orthopedics on 10 September 2007. A magnetic resonance imaging as then accomplished on 26 September 2007 and revealed a herniated disc at L4-5. At a follow-up orthopedic appointment on 15 October 2007, he was noted to have decreased sensation in the left L-4 distribution and tenderness of the left lumbar muscles; the examination was otherwise unremarkable. Electrodiagnostic studies 2 weeks later showed a chronic L5 radiculopathy. He was also noted to have “subtle” left sided weakness (5-/5) for left hip abduction, knee flexion, and great toe extension in orthopedics that same day. He was evaluated in the pain clinic on 14 January 2008 and noted to have a normal neurological examination and no significant difficulty with back flexion and extension. He had a narrow gait, but some difficulty rising from a chair. He was given epidural steroid injections a week later. On 11 February 2008, he was issued an L3 profile and referred for MMRB (MOS Medical Review Board). He had a second injection on 22 February 2008. A letter from the CI dated 5 March 2008, 2 weeks after the second injection, noted that he felt much better and had requested a P2 profile, but was too “far along the MEB process” (for return to duty). He was seen again on 8 April 2008 in the pain clinic and noted persistent pain; he declined a third injection. The neurological examination was normal. He was tender to deep palpation over the left sacroiliac joint (where the spine joins the pelvis) and left lumbar muscles. At the MEB examination on 13 June 2008, the CI reported persistent LBP and numbness of the left leg. The MEB physical examiner checked that the examination was normal. The narrative summary was on 25 June 2008 and noted persistent pain. No separate examination was accomplished. The CI was sent to physical therapy for range-of-motion (ROM) measurements (below). The last clinical visit in evidence prior to separation was dated 6 January 2009 in orthopedics. The CI reported that the LBP was dramatically better and the he was interested in reclassification. The examiner concurred.

At the VA Compensation and Pension (C&P) examination performed on 15 April 2009, 3 months prior to separation, the CI reported left leg numbness with activity and persistent pain. He had no difficulty walking long distances, but had pain after standing for 30 minutes. He reported incapacitation twice. Both instances were for 48 hours after the injections. On examination, he had a good posture and normal gait. The neurological examination was normal. The ROM is charted below. Two weeks after separation, the CI was evaluated for a possible head injury. The examination of the back showed normal sensation, reflexes, and gait. The motor examination was normal other than a reduced left TA (assume tibialis anterior muscle lifts the foot, innervated by L4, L5, S1). This is not consistent with a normal gait. The ROM was noted to be functional with flexion to the mid tibia (shin bone). The CI had a second VA C&P examination on 26 August 2009, less than 2 months after separation. The CI reported flares every 3 to 4 months which lasted 2 to 4 weeks. He reported difficulty walking, sitting, and driving during a flare. On examination, his gait and posture were normal. Spasm, tenderness, and atrophy were absent. The left knee reflex was reduced compared to the right and there was diminished sensation in the L4-5 dermatome. The motor function was normal.

The goniometric 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 ~9 Mo. Pre-Sep VA C&P ~3 Mo. Pre-Sep VA C&P ~2 Mo. Post-Sep
Flexion (90 Normal) 85 65 90
Combined (240) 220 200 220
Comment Limited by pain. No spasm. AO Normal gait. No pain with ROM. No loss with repetition
§4.71a Rating 10% 10% 10%

The Board directed attention to its rating recommendation based on the above evidence. The PEB and VA both rated the back at 10% using the codes 5243 (intervertebral syndrome) and 5242 (degenerative arthritis of the spine) respectively. The ROM supports a 10% rating. Absent incapacitation beyond the few days after injections, spasm, or ankylosis, the Board found no route to a higher rating than that adjudicated by both the PEB and VA. The Board also considered if an unfitting radiculopathy was present at separation. It noted that the gait was consistently recorded as normal and muscle atrophy was absent. The neurological examination was typically normal, but when deficits were recorded, they were not consistent between examinations. The Board concluded therefore that the evidence does not support the presence of an unfitting radiculopathy at separation and an additional disability rating cannot be recommended rating. 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.


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 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 re-characterization of the CI’s disability and separation determination.
The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140513, 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, AR20150010562 (PD201402348)


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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