RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00216
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20061231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Duty E3, Bradley Fighting Vehicle Mechanic, medically separated for “chronic back pain” with a disability rating of 10%.

CI CONTENTION:  He was not evaluated for his anxiety, hip pain or a leg numbness condition.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20061128	VARD – 20070424	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5242	10%	DDD Lumbar Spine	5243	10%	20070228	
COMBINED RATING:  10%		COMBINED RATING FOR ALL VA CONDITIONS:  20%		

ANALYSIS SUMMARY:

Chronic Back Pain.  The record shows onset of the CI’s atraumatic low back pain (LBP) in 2003.  He was treated with medications, duty restrictions, and injections, but had persistent pain.  The CI was evaluated in the pain clinic on 31 March 2006, 9 months prior to separation, and noted to have normal range-of-motion (ROM), gait, and neurological examination.  Magnetic resonance imaging (MRI) showed normal discs with minimal degenerative change in the facets (joint surfaces between the vertebrae).  At the Medical Evaluation Board (MEB) examination on 6 September 2006, the CI reported progressive LBP since October 2003.  The MEB physical examiner noted painful-limited motion, but a normal gait and neurological examination.  A repeat pain clinic evaluation on 26 September 2006, 3 months prior to separation, noted limited ROM with pain from multiple maneuvers, but no radicular symptoms.  On examination, the gait, posture and neurological examination were normal.  A discogram on 2 October 2006 showed concordant pain at L5-S1 (indicating that this disc was causal of his pain).  During the narrative summary (NARSUM) dated 6 November 2006, the CI was tender to palpation over the back without muscle spasm.  The neurological examination was normal.  The formal ROM measurements were performed by physical therapy 9 days later on 15 November 2006, 6 weeks prior to separation.  The ROM was limited and painful.  The gait was abnormal secondary to guarding, but spasm was absent.

At the VA Compensation and Pension (C&P) examination performed on 28 February 2007, 2 months after separation, the CI reported ongoing LBP, but none at rest.  No assistive device was in use.  He denied incapacitation.  On examination, the gait and neurological examination were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the back at 10%, coded 5299-5242 (spinal fusion) and 5243 (intervertebral disc syndrome), respectively.  The Board considered the evidence.  The MEB examination supports a 20% rating due to an abnormal gait secondary to guarding.  However, multiple other examinations prior to separation and the VA C&P examination after separation all document a normal gait.  The PT examination is an outlier and thought to be less representative of the back condition than the C&P examination.  Therefore, IAW VASRD §4.7 (higher of two evaluations), the VA examination is used for rating purposes.  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 chronic back pain condition.

BOARD FINDINGS:  In the matter of the chronic 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.  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 20140101, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX, AR20160005826 (PD201400216)

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:  

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA