RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02554
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040727

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

CI CONTENTION:  The applicant makes no specific contention in their application.  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 – 20040602	VARD - 20050822	
Condition	Code	Rating	Condition	Code	Rating	Exam*	
Chronic Low Back Pain…	5237	10%	DDD L5-S1…	5243	20%	20040824	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	
*Also used 20050714 Exam

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain (LBP) began as early as October 1998 with no associated injury or trauma.  Lumbar spine magnetic resonance imaging in the fall of 2003 showed moderate degenerative changes, a transitional lumbosacral vertebra (normal variant) and “tiny disc protrusions”, without nerve root displacement.  At a single physical medicine evaluation 7 October 2003, the CI reported numbness and tingling (N/T) of the bilateral lower extremities (LEs) when lying down, but at all other treatment visits the CI reported localized LBP without out radiation or LE N/T.  There was no surgical indication.  Despite treatment, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of his military specialty, so he was referred for an MEB.  

The range of motion (ROM) examinations 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)	NARSUM ~4 Mos. Pre-Sep
	PT ~4 Mos. 
Pre-Sep
	VA ~1 Mo. 
Post-Sep
	VA ~12 Mos.
Post-Sep
	
Flexion (90 Normal)	55 (52, 54, 56)	75%	55 (55)	50 (50)	
Extension (30)	15 (12, 14, 15)	75%	10 (10)	20 (20)	
§4.71a Rating	20%	10%	20%	20%	

The MEB NARSUM examination on 18 March 2004 (4 months prior to separation) noted complaints of LBP, worse with extension or rotation.  The CI reported experiencing some difficulty with sleep due to the back pain.  Physical examination showed no “lumbar abnormalities” or sacroiliac joint pain and a mildly antalgic gait.  Strength, reflexes and sensation were all normal and testing for nerve root irritation was negative.  The ROM and additional examination findings are indicated in the chart above.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 6 April 2004, the CI reported LBP, rated 5/10 in severity, without LE N/T.  Physical examination was checked as abnormal, and noted only “painful leg lift.”  The examiner noted the CI had been on profile for more than 1 year, with physical limitations of no running, sit-ups, or battle gear.  At the time of the PT clinic appointment on 12 April 2004 (4 months prior to separation), the CI reported LBP, rated 4/10 in severity, and that he was able to walk 1/2 mile, 4 times per week.  The ROM and additional examination findings are reflected in the chart above.  

At the VA Compensation and Pension (C&P) General medical examination on 24 August 2004 (a month after separation), the physical examination showed normal LE strength, sensation, and reflexes.  The ROM and additional examination findings are reflected in the chart above.  At a second VA C&P Internal Medicine examination 14 July 2005, performed 12 months after separation, the CI reported constant LBP, rated 8/10, with intermittent radiation down the bilateral LEs.  He reported the pain could occur with no provocation or be brought on by physical activity such as walking, standing, or sitting, and was alleviated by rest or over-the-counter pain medication.  The CI reported difficulty with bending, crouching, stooping, lifting, carrying, and routine activities, such as walking, shopping, gardening, taking out the trash, and pushing a lawn mower.  He reported being able to function during exacerbation with or without medication, and denied incapacitation or bed rest directed by a physician.  He did not lose work time due to this condition.  On examination provocative maneuvers for nerve root irritation were negative.  The ROM and additional examination findings are reflected in the chart above.  The examiner indicated that there was no evidence of intervertebral disc syndrome with chronic and permanent nerve root involvement or bladder or bowel dysfunction.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP 10%, coded 5237 (lumbosacral strain), citing “tenderness to palpation.”  The VA rated the LBP 20%, coded 5243 (intervertebral disc syndrome), based on the VA C&P examinations 1 month and 1 year after separation, citing limitation of forward flexion.  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the NARSUM and both VA exams.  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  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 low back pain, coded 5237.  

The Board also considered if there was evidence in the record to support recommending peripheral nerve impairment due to the back condition as separately unfitting and eligible for additional disability rating.  While the CI reported bilateral LE N/T at one visit in the STR and radiating pain to the bilateral LEs at the C&P one year after separation, radiating pain is subsumed under the general spine rating criteria, which specifically state “with or without symptoms such as pain (whether or not it radiates).”  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a and there was no objective evidence of a motor or sensory deficit with functional impairment that could be considered separately unfitting for duty.

BOARD FINDINGS:  In the matter of the chronic low back pain, the Board unanimously recommends a disability rating of 20%, coded 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	5242	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140528, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

JUL 19 2016

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160007629 (PD201402554)

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