IN THE CASE OF:	  

		BOARD DATE:	  29 October 2014

		DOCKET NUMBER:  AR20140000611 


THE BOARD CONSIDERED THE FOLLOWING EVIDENCE:

1.  Application for correction of military records (with supporting documents provided, if any).

2.  Military Personnel Records and advisory opinions (if any).


THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE:

1.  The applicant requests reconsideration of his previous request for consideration by a medical evaluation board (MEB).

2.  The applicant states he has documentation of earlier dates of symptoms than those considered by the Board.  This medical documentation notes he suffered a back injury and received treatment in theater in July 2009 and November 2010.  He has not been able to locate every physical profile he was issued, but he does have one prior to that considered by the Board.  He aggravated his groin in January 2010 and he now has medical documentation showing he has a bulged disc due to the fall.  He never underwent magnetic resonance imaging (MRI) to fully view the injury to better help determine the extent of his injury and how he was not physically able to fully function as a Soldier.  He has since had an MRI by the Department of Veterans Affairs (VA) hospital and located the source of his chronic back pains caused during his deployment and aggravated while stationed at Fort Hood, TX, in January 2010.  He is currently looking for the source of his groin pains associated with his back pains.

3.  The applicant provides:

* Standard Form 600 (Chronological Record of Medical Care), dated 26 July 2009 (2 pages)
* DD Form 689 (Individual Sick Slip), dated 20 January 2010
* DD Form 689, dated 8 July 2010
* Standard Form 600, dated 2 November 2010


* imaging report, dated 5 March 2014
* VA medical records

CONSIDERATION OF EVIDENCE:

1.  Incorporated herein by reference are military records which were summarized in the previous consideration of the applicant's case by the Army Board for Correction of Military Records (ABCMR) in Docket Number AR20130002209 on 26 November 2013.

2.  The applicant provided a Standard Form 600, dated 26 July 2009, showing he complained of lower back pain and subsequent medical documents which were not previously considered by the Board.  This is new evidence which will now be considered.

3.  He enlisted in the Regular Army on 22 May 2008.  He served in Iraq from 28 April 2009 to 9 April 2010.

4.  A Standard Form 600, dated 26 July 2009, shows he was treated on that date by the 1st Air Cavalry Brigade troop medical clinic.  He complained of lower back pain and right knee pain in duration of 10 days.  He reported his history of physical trauma as a fall from a light medium tactical vehicle (utility truck) the previous week with back and knee pain ever since.  His lower back exhibited tenderness on palpation, no tenderness on palpation of the knee, and no muscle spasm of the knee.  He stated he was continuing working on construction projects and lifting with some pulling and discomfort.  His pain could be controlled.  The x-ray of his lumbosacral spine was normal.  He was prescribed a nonsteroidal anti-inflammatory drug with a muscle relaxer at bedtime for 5 days accompanied by stretching/strengthening exercises and proper lifting techniques.

5.  A DD Form 689, dated 20 January 2010, shows he reported to the local clinic for back and groin pain in duration of 4 days.  He was restricted from running, jumping, marching, carrying a rucksack, and lifting more than 10 pounds until his scheduled follow-up examination.

6.  A DD Form 689, dated 8 July 2010, shows he reported to the local clinic for groin pain.  He was restricted from taking an Army Physical Fitness Test until cleared.  He was otherwise able to perform physical training at his own pace and distance.

7.  A Standard Form 600, dated 2 November 2010, shows he was treated on that date by the Darnall Army Medical Center Physical Therapy Clinic, Fort Hood, TX, for groin pain.  He was educated on the anatomy and function of the abdominal muscle and muscle supporting the spine, as well as the importance of these muscles for decreasing low back pain over time with consistent training and strengthening.

8.  As noted in the previous Record of Proceedings, a DA Form 3349 (Physical Profile) shows he was issued a temporary physical profile on 4 January 2011 for low back pain secondary to a fall.  Medical documentation he provided shows he was noncompliant with treatment, both with medicines and with his recommended physical regimen.  His pain was attributed to muscle strain and was often referred to as lumbago.  The persistence of his pain was attributed to his weight, his level of activity, and his noncompliance with treatment.

9.  Also noted in the previous Record of Proceedings, he provided medical documentation, dated February 2011 and March 2011, which shows he was treated for lower back pain.  One document stated he had no history of trauma.

10.  On 22 July 2011, he was honorably released from active duty under the provisions of Army Regulation 635-200 (Active Duty Enlisted Administrative Separations), paragraph 16-7, for reduction in force.

11.  His records do not contain evidence that he was issued a permanent physical profile for any medical condition.

12.  A VA Progress Note, dated 6 March 2012, shows he complained of back pain and pain in his testicles.  The history of present illness notes he has pain off and on related to a service-connected testicle injury and chronic back pain from a fall from a truck.  The trauma is identified as a 2009 back injury and 2009 groin injury resulting from a strain filling burn bags.  His musculoskeletal examination revealed normal gait and station; normal extremities; and limited side bend, flexion, and extension of back range of motion.

13.  A VA imaging report, dated 5 March 2014, shows no areas of increased radioactive tracer absorption of concern for metastatic disease.  Multiple foci of increased radioactive tracer localization were noted in the bilateral joints connecting the breastbone and the collarbone, cervical spine, bilateral hips, and bilateral knees consistent with mild degenerative disease.  The remainder of his skeleton was unremarkable.  There was no evidence of increased bone remodeling in the lumbar spine and pelvis.

14.  Army Regulation 40-501 (Standards of Medical Fitness), paragraph 7-4, states that if the physical profile is permanent, the profiling officer must assess if the Soldier meets the medical retention standards of chapter 3.  Those Soldiers serving on active duty who do not meet the medical retention standards must be referred to an MEB.

15.  Army Regulation 635-40 (Physical Evaluation for Retention, Retirement, or Separation) governs the evaluation of physical fitness of Soldiers who may be unfit to perform their military duties because of physical disability.  The unfitness must be of such a degree that a Soldier is unable to perform the duties of his or her office, grade, rank, or rating in such a way as to reasonably fulfill the purposes of his or her employment on active duty.

16.  Army Regulation 635-40, paragraph 2-2b, as amended, provides that when a member is being separated for any reason other than physical disability, his continued performance of duty creates a presumption of fitness which can be overcome only by clear and convincing evidence that he was unable to perform his duties or that acute grave illness or injury or other deterioration of physical condition, occurring immediately prior to or coincident with separation, rendered the member unfit.

DISCUSSION AND CONCLUSIONS:

1.  The applicant's contends that he should be considered by an MEB for a back injury he suffered in theater in July 2009.

2.  The medical evidence shows he was treated on that date by the 1st Air Cavalry Brigade troop medical clinic for lower back pain and right knee pain caused by a fall from a utility truck the previous week.

3.  His records show he was issued a temporary physical profile for low back pain secondary to a fall on 4 January 2011, nearly 18 months later.  However, his records do not contain evidence that he was issued a permanent physical profile for any medical condition at any time.

4.  Army Regulation 40-501 states the profiling officer must assess if the Soldier meets the medical retention standards of chapter 3 if the physical profile is permanent.  Those Soldiers serving on active duty who do not meet the medical retention standards must be referred to an MEB.

5.  In view of the foregoing, there is no evidentiary basis for granting the requested relief.



BOARD VOTE:

________  ________  ________  GRANT FULL RELIEF 

________  ________  ________  GRANT PARTIAL RELIEF 

________  ________  ________  GRANT FORMAL HEARING

____X____  ___X_____  ___X_____  DENY APPLICATION

BOARD DETERMINATION/RECOMMENDATION:

The evidence presented does not demonstrate the existence of a probable error or injustice.  Therefore, the Board determined the overall merits of this case are insufficient as a basis to amend the decision of the ABCMR set forth in Docket Number AR20130002209, dated 26 November 2013.



      ____________X_____________
                  CHAIRPERSON
      
I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case.

ABCMR Record of Proceedings (cont)                                         AR20140000611



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ABCMR Record of Proceedings (cont)                                         AR20140000611



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