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AF | PDBR | CY2014 | PD-2014-02558
Original file (PD-2014-02558.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-02558
BRANCH OF SERVICE: Army  BOARD DATE: 20150130
SEPARATION DATE: 20050225


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Trainee) medically separated for a lumbar spine condition. The condition could not be adequately rehabilitated to meet the physical requirements of his initial entry training or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Low back pain (LBP) 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 low back pain ... no radiculopathy” as unfitting, rated 0% citing criteria of the U. S. Army Physical Disability Agency (USAPDA) pain policy. 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 :

IPEB – Dated 20050131
 VA* - Based on Service Treatment Record (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain… 5237 0% Low Back Pain w/ Small Disc Bulge L5-S1 5237 0%* STR**
Other x 0 (Not In Scope)
 Other x 0
RATING: 0%
 RATING: 0%
* Derived from VA Rating Decision (VA RD ) dated 200 50811 (most proximate to date of separation ( DOS ) )
**Initial non-compensable rating based on failure to report for scheduled examination





ANALYSIS SUMMARY:

Lumbar Spine Condition. The STR contains no probative entries for the condition prior to the narrative summary (NARSUM) for the MEB which was initiated prior to completion of basic training (total length of service was 8 months). There is a single entry from December 2004 noting “9/10 severe” lower back pain with an MEB in progress, recording no physical findings. There are MEB range-of-motion (ROM) measurements from physical therapy on 7 January 2005, 6 weeks prior to separation, recording a flexion of 70 degrees (normal 90) and combined ROM of 170 degrees (normal 240), without documentation of other ratable findings. The NARSUM was conducted on 14 January 2005 (5 weeks prior to separation), and documents an onset of LBP in basic training without known injury or precipitant. It noted imaging (magnetic resonance imaging) findings of a “very small” disc bulge at L5/S1 without spinal cord or nerve root impingement (non-surgical). The examiner conveyed a report of constant pain of the entire spine and all four extremities which the CI rated 9/10, “24/7, but has little difficulty sleeping.” Note was made of “increasing pain with any activity,” with the added comment, “He is remarkably debilitated for his degree of diagnostic criteria.” The physical exam described the CI as “smiling and conversing throughout this interview” with “no muscle spasm;” and, detailed normal neurological findings with 5/5 motor strength. There is no NARSUM or STR comment regarding gait or spinal contour, although there are multiple references to normal gait and contour in the post-separation VA file. The delayed (15 months after separation) VA Compensation and Pension examination described “non-radiating” pain rated 8-9/10; and, the exam noted the absence of tenderness or spasm and normal neurological findings. Recorded ROM was flexion to 80 degrees and combined ROM of 185.

The Board directed attention to its rating recommendation based on the above evidence. The PEB’s 0% rating under code 5237 (lumbosacral strain) was supported by the USAPDA pain policy, but was not consistent with VASRD §4.71a criteria for the MEB ROM measurements. The latter is the only formal ROM evidence proximate to separation; and, both the flexion 70 degrees and combined ROM 170 is a §4.71a criterion for a 10% rating. The significantly less probative ROM evidence from the VA also satisfies 10% criteria. There was no evidence of ratable peripheral nerve impairment which would provide for additional rating, or documentation of incapacitating episodes which would provide for a higher rating under that formula. After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the lumbar spine condition; proposing code 5243 (intervertebral disc syndrome) for its clinical compatibility.


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. As discussed above, PEB reliance on the USAPDA pain policy for rating was operant in this case and it was adjudicated independently of that policy by the Board. In the matter of the lumbar spine condition, the Board unanimously recommends a disability rating of 10%, coded 5243, 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:

CONDITION VASRD CODE RATING
Lumbar Disc Disease 5243 10%
COMBINED 10%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140507, 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, AR20150010611 (PD201402558)


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 10% 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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