RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01233
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081001

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Land Combat Electronic Missile System, medically separated for “low back pain due to lumbar degenerative disc disease and spondylolisthesis,” with a disability rating of 10%.  

CI CONTENTION:  The CI continues to experience lower back with impacts his daily life.  The CI’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 - 20080630	VARD - 20090122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low back Pain…	5239	10%	Lumbar Degenerative Disc Disease with Spondylosis	5239-5242	20%	20081010	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain (LBP) due to Lumbar Degenerative Disc Disease (DDD) and Spondylolisthesis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 2007 and worsened during physical training for mobilization.  Magnetic resonance imaging studies in September 2007 showed multilevel DDD without nerve impingement or central spinal canal stenosis and X-ray studies in May 2008 showed possible mild spondylolisthesis at L5-S1 otherwise no significant pathology.  During an orthopedic clinic appointment on 2 October 2007, 12 months before separation, the CI reported improved LBP, graded 2/10.  On examination, lower extremity strength, sensation and reflexes were normal and straight leg testing (SLR) for radiculopathy was negative bilaterally.  There was no surgical indication; however, the CI had spinal injections which provided temporary relief.  In the year before separation, eight exams in the STR addressed muscle spasm - six noted muscle spasm was present associated with a normal gait and spinal contours, with “abnormal” range of motion (ROM); two documented no muscle spasm, and of these, one noted “abnormal,” painful ROM.  Despite treatment, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for an MEB.  

During the physical therapy appointment on 2 June 2008 for MEB ROM, 4 months before separation, the examiner recorded no muscle spasms or guarding; no abnormal spinal contour and gait was normal.  The thoracolumbar ROM was forward flexion of 75 degrees (90 degrees normal) with a combined ROM of 170 degrees (240 degrees normal) with pain in all planes.  The examiner noted “good effort was placed by patient.”

At the MEB examination (recorded on DD Form 2808) dated 5 June 2008, 4 months prior to separation, the physical exam showed a mild antalgic gait.  

The MEB NARSUM examination on 11 June 2008 (4 months prior to separation) noted complaints of constant LBP without radiating pain, weakness, or paresthesia (abnormal sensations, often numbness and tingling) with flares-ups twice a week that lasted 3-4 hours.  There was bilateral tenderness without guarding or muscle spasm.  Lower extremity strength sensation and reflexes were normal and SLR was negative.  Back ROM was forward flexion of 80 degrees and the combined ROM was 195 degrees with pain in all planes at the end ranges.  

At the VA Compensation and Pension (C&P) examination on 10 October 2008, performed 9 days than after separation, the CI reported 7/10 intermittent, non-radiating LBP which occurred as often as 3 times per day and lasted up to 2 hours.  On examination there was a normal gait.  There was muscle spasm present, without radiation of pain on examination.  Lower extremity strength, sensation, and reflexes were normal and SLR was negative.  Thoracolumbar (TL) ROM was flexion of 45 degrees with a combined ROM of 195 degrees.  The examiner stated “There is no intervertebral disc syndrome with nerve root involvement noted on examination today.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% coded 5239 (spondylolisthesis or segmental instability), citing consideration of functional loss IAW VASRD §4.10, §4.40, §4.45, and §4.59.  The VA rated the back condition 20% coded 5239-5242 (spondylolisthesis or segmental instability - degenerative arthritis of the spine), based on the VA C&P examination 9 days after separation, citing, limitation of forward flexion.  The Board noted that the MEB NARSUM and physical therapy MEB evaluations support a 10% rating based on forward flexion or combined TL ROM, while the C&P exam supports a 20% rating for forward flexion of “greater than 30 degrees but not greater than 60 degrees.”  The C&P exam was the most proximate exam to the date of separation and exams in the STR frequently noted the presence of muscle spasms and abnormal lumbar motion without any accompanying quantitative ROM data.  After deliberations, the Board noted that with resolution of reasonable doubt in favor of the CI IAW VASRD §4.3 (Reasonable doubt), some exams which noted muscle spasm were likely associated with decreased ROM sufficient to support a 20% rating as well as the C&P exam, and therefore the evidence provides sufficient support for the 20% rating for he back condition at the time of separation.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula and there was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the LBP condition, coded 5239-5242.  

BOARD FINDINGS:  In the matter of the chronic LBP due to lumbar DDD and spondylolisthesis condition, the Board unanimously recommends a disability rating of 20%, coded 5239-5242 IAW VASRD §4.71a  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior to medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain…	5239-5242	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140308, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

JUL 28 2016

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160007276 (PD201401233)

1. 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, accept the Board's recommendation to modify the individual's disability rating to 20% without re-characterization of the individual's separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF:
( ) DoD PDBR
( ) DVA