RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01540
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20091026

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Infantryman, medically separated for “lumbosacral strain,” with a disability rating of 10%.

CI CONTENTION:  His condition continues to worsen and negatively impacts his daily activities.  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 - 20090814	VARD - 20100427	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Degenerative Changes (L4-5), Thoracolumbar Spine	5242	10%	No Show	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Lumbosacral Strain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in mid-2007 after a fall landing on his back.  Magnetic resonance imaging studies on 21 August 2007 showed discovertebral degenerative change at L4-5 causing moderate to severe central canal stenosis.  At the time of the neurosurgery clinic appointments on 29 October 2007 and 28 January 2008, the examiner noted that surgery was not indicated and recommended physical therapy and injection therapy.  
At the time of the orthopedic clinic appointment on 10 June 2009, the CI reported physical therapy did not help and he had low back pain described as a stabbing pain with numbness in his left leg with standing or sitting.  On examination the CI had a normal gait and spinal contour, no paraspinal muscle spasms, normal reflexes, normal strength, and examination maneuvers for radicular signs were negative.  Tenderness on palpation of the left paraspinal region and decreased sensation on the left lateral thigh was noted.  The MEB NARSUM examination performed on 26 July 2009 (3 months prior to separation) noted complaints of sharp stabbing pain daily with left leg numbness.  Physical exam showed a normal gait.  Straight leg testing was positive and decreased sensation in the left lateral thigh was noted along with tenderness to palpation of the paraspinal muscles.  Thoracolumbar range of motion (ROM) measurements performed by physical therapy, dated 15 July 2009, were flexion 90 degrees (normal 90) and combined ROM 215 degrees (normal 240) after repetition.  The CI failed to attend his scheduled VA Compensation and Pension (C&P) examination on January 2010.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under code 5237 (lumbosacral strain), citing tenderness and painful limited motion with a normal gait.  The VA also assigned a 10% rating with code 5242 (degenerative arthritis of the spine) based on the service records.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB physical therapy examination.  Although there was muscle spasm, it was not 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 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 lumbar spine condition.

BOARD FINDINGS:  In the matter of the lumbosacral strain 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 20140218, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

JUL 2 8 2016

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 XXXXXXXXXXXXXXXXXXXX, AR20160006751 (PD201401540)

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 1 O, 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