RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-01171
BRANCH OF SERVICE: Army		SEPARATION DATE:  20091027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Patriot Operator/Maintainer, medically separated for “chronic low back pain,” with a disability rating of 10%.

CI CONTENTION:  Contends for his back and major depressive disorder.  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 - 20090804	VARD - 20100406	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	DDD Lumbosacral Spine	5243	10%	20091009	
Major Depressive Disorder	Not Unfitting	Depression	9434	30%	20091015	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  The record shows that the CI developed atraumatic low back pain (LBP) in 2006 which was refractory to physical therapy, medications, and duty restrictions.  Magnetic resonance imaging (MRI) on 18 March 2009, 7 months prior to separation, showed mild degenerative disc disease (DDD) at L3-4, but was otherwise unremarkable.  At the Medical Evaluation Board (MEB) examination on 4 February 2009, 9 months prior to separation, the range of motion (ROM) was limited by pain.  The back was tender, but spasm absent.  The MEB narrative summary (NARSUM) was done the same day and noted the above examination.  The ROM is charted below and was limited by pain.  The neurological examination and gait were normal.  At the VA Compensation and Pension (C&P) examination performed on 9 October 2009, 2 weeks prior to separation, the CI reported a 4-year history of LBP without antecedent trauma.  He had been placed on quarters for 2 days shortly after he was diagnosed, but not since.  He did not use a brace or other assistive device.  His posture and gait were normal.  The ROM was normal and pain free.  His neurological examination was normal.

The Board directed attention to its rating recommendation based on the above evidence.  Two ROM examinations support a 10% rating; the VA examination, the most proximate to separation, supports a 0% (non-compensable rating).  The Board found no route to a rating higher than the 10% rating adjudicated by both the PEB and VA, coded 5299-5237 (analogous to lumbosacral strain) and 5243 (intervertebral disc syndrome), respectively.  Additionally, there was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula or evidence of ratable peripheral nerve impairment which would provide for additional 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 chronic LBP condition.

Contended PEB Conditions.  The major depressive disorder carried an S1 profile.  It was not implicated in the commander’s statement and was judged to meet retention standards.  It was reviewed and considered by the Board.   There was no performance based evidence from the record that it significantly interfered with satisfactory duty performance.  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 contended major depressive disorder and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended major depression disorder, the Board unanimously recommends no change from the PEB determination as not unfitting.  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, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160006038 (PD201401171)

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