RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01098
BRANCH OF SERVICE:  Army	Date of sepAration:  20081006

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Shower/Laundry and Clothing Repair Specialist, medically separated for “chronic back pain related to symptomatic idiopathic scoliosis without myelopathy,” with a disability rating of 10%.  

CI CONTENTION:  The CI contended for his unfitting back condition.  The applicant’s 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 - 20080820	VARD - 20090515	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5237	10%	Chronic Back Pain with Limitation of Motion	5299-5239	10%	20090410	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), 6 months prior to separation, the CI complained of a history of recurrent lower back pain without any history of trauma.  Radiographic studies showed three scoliotic (side-bending) curvatures of the thoracic and lumbar spine.  The CI was not a surgical candidate.  The NARSUM noted the CI had failed all conservative treatment measures and did not complain of any pain, numbness or tingling extending into his lower extremities or upper extremities.  The physical examination noted there was “full range of motion [ROM]” of the back with tenderness to palpation along the thoracic, thoracolumbar and lumber region of his back without palpable deformity or spasm.  On forward flexion there was a noticeable elevation of the right scapula and prominence of paraspinous muscles on the right compared to the left.  There was no evidence of muscle atrophy or hypertrophy in the back, upper or lower extremities.  The motor sensory and reflex examinations were normal.  Physical therapy (PT) formal back ROM testing is summarized below.  

At the VA Compensation and Pension (C&P) exam performed 7 months after separation, the CI reported that his back pain began in August 2007 while in basic training, that he was offered PT vice a discharge, choosing PT that made his situation worse.  The CI further reported that he had not had any back injections and did not wear a brace.  Physical examination noted normal gait, obvious curvature abnormality from the thoracic to the lumbar spine area, no tenderness, and no spasm.  There was “some” muscle hypertrophy in the right thoracic to lumbar areas.  Motor and sensory exams were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous code 5299-5237 (lumbosacral strain), citing combined ROM of 207 degrees and IAW VASRD §4.10, §4.40, §4.45 and §4.59.  The VA also assigned a 10% rating using an analogous code 5299-5239 (spondylolisthesis or segmental instability) based on the VA C&P examination 7 months after separation, citing ROM criteria.  The Board agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on both the PT and VA exams.  The NARSUM exam would also be ratable at 10% for tenderness.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no associated radiculopathy for separate peripheral nerve 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 for the back condition.  

BOARD FINDINGS:  In the matter of the back 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 20140227, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160005602 (PD201401098)

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
( ) OVA