RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-00660
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041213

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Signal Interceptor) medically separated for back pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  The CI’s profile did allow for alternate physical fitness testing to satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “left lumbar paraspinal myofascial pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated his low back pain (LBP) as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI elaborated no specific contention in his application.  

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 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 20040809	VA* - (~1 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Sided LBP…	5299-5237	10%	Low Back Paraspinal Strain with Sacroiliac Joint Strain	5237	10%	20041103	
Other x 0 (Not In Scope)	Other x 4	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20041221 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Left Sided Low Back Pain ... Condition.  The record shows that the CI first developed LBP during basic training following a road march.  Over the next several years, he was treated with duty restrictions, medications, and physical therapy (PT) without resolution.  X-rays on 11 September 2001 were normal.  An MRI on 12 March 2003 was normal.  A repeat x-ray on 9 June 2004 showed a congenital defect (spina bifida occulta) at S1, but was otherwise normal.  At the MEB examination on 24 May 2004, the CI reported chronic LBP.  The examiner noted a normal neurological and spine examination.  The CI was seen in physical medicine on 9 June 2004 for the MEB.  The CI reported increased LBP with vigorous physical activity such as mowing a lawn, but otherwise was relatively pain free.  He denied neurological symptoms.  On examination, his gait was normal and he was able to get on and off the examination table without difficulty.  He was tender over the paraspinal muscles.  The range-of-motion (ROM) was full and pain free.  The neurological examination and gait were normal.  Signs of non-organic pain were absent (normal).  He was thought to have a myofascial pain syndrome.  The narrative summary (NARSUM) was dated 7 July 2004, 5 months prior to separation.  The CI was again tender over the para-lumbar muscles, but the gait, ROM, and neurological examinations were normal.  The left side paraspinal muscles were noted to be firm compared to the right, but spasm was not specifically documented.  At the VA Compensation and Pension (C&P) exam performed on 3 November 2004 the CI reported the he had more pain with extension than forward flexion.  His ROM decreased 30% in flares (by his report), but he denied incapacitation.  His gait and ROM were normal with discomfort at maximal extension (which was greater than VA normal limits).  The neurological examination 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 ~5 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (90 Normal)	Normal	90	
Combined (240)	Normal	240	
Comment	Tenderness, Spasms	Discomfort on extension	
§4.71a Rating	10%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the back condition at 10%, coded 5237 (lumbosacral strain) although the PEB did so analogously (5299-5237).  The Board reviewed the evidence and found no route to a higher rating.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination 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 left sided 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 20131230, 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 XXXXXXXXXXXXXXXXXXXXXXXXXX, AR20160003066 (PD201400660)

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