RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02604
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060523

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Dental Specialist, medically separated for “chronic back pain” with a disability rating of 0%.  

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 - 20060421	VARD - 20061211	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain…	5299-5237	0%	HNP of the Lumbosacral Spine	5243	10%	20061007	
COMBINED RATING:  0%	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), the CI’s low back pain began in June 2004 with no associated injury or trauma.  Radiographic studies performed in December 2005 showed vertebral disc bulges at two levels of the lower spine.  There was no surgical indication.  Despite conservative 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 a 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)	Ortho ~4 Mos. Pre-Sep	PT ~3 Mos. Pre-Sep	MEB ~3 Mos. Pre-Sep	VA ~4 Mos. Post-Sep	
Flexion (90 Normal)	“Touches Knees”	90	90	90	
Combined (240)	>120 ; <235	215	225	240	
Comments:  Applied Note (2)	Gait normal; no tenderness or spasm (see text)	Painful motion (extension 15 of 30 degrees)	Normal gait (extension 15 of 30 degrees)	Normal gait; no tenderness or spasm	
§4.71a Rating	10%-20%	10% (PEB 0%)	10% (PEB 0%)	0% (VA 10%)	

At the time of the orthopedic clinic appointment on 10 January 2006 (4 months prior to separation), the CI reported chronic low back pain that bothered him when he tried to bend over to treat patients, tried to run or do sit-ups.  Activities of daily living were not impacted by the condition.  On examination strength, sensation, and reflexes were all normal and testing for nerve root irritation was negative.  As depicted in the chart above, ROM was reported as “normal,” except forward flexion was reported as the CI “touches knees” (knee level or just below the knees was approximated as roughly 45-60 degrees forward flexion for charting).  The diagnosis was “herniated disc (L4- L5) central:  without radiculopathy.”  The PT examination performed 6 March 2006 reported pain on lateral flexion and rotation.  

At the MEB examination (recorded on DD Forms 2807, 2808, and addendum) performed 7 March 2006 (3 months prior to separation), the CI reported back pain with numbness and tingling in his left leg.  Physical exam showed normal strength, sensation, and reflexes.  Testing for nerve root irritation was negative.  The MEB NARSUM examination on 3 April 2006 (2 months prior to separation) noted complaints of constant low back pain exacerbated when the CI bent over to treat patients.  He was able to walk or ride a bicycle, but could not run.  The NARSUM referred to the MEB exam for physical examination.  

At the VA Compensation and Pension (C&P) examination on 7 October 2006 (4 months after separation), the CI reported daily, moderate back pain, lasting 1-2 days, which radiated to the left foot.  There was no reported limitation to walking and no assistive devices were used.  Physical exam showed normal strength, sensation, and reflexes.  Testing for nerve root irritation was negative.  Radiological study was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain 0%, coded 5299-5237 (analogous to lumbosacral strain), citing combined ROM “greater than 240 degrees.”  The VA rated the back condition 10%, coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 4 months after separation, citing pain on motion.  There was a disparity between examinations with implications for the Board's rating recommendation.  The Board deliberated the probative value of these conflicting evaluations, and carefully reviewed the entire file for corroborating evidence.  The combined ROM from both the PT and MEB exams were greater than 120 degrees but not greater than 235 degrees when note 2 of the general spine formula was applied (truncating ROMs to maximum of VASRD normal).  All service exams would support a 10% rating for ROM limitation (or alternatively for pain on motion reported at the PT exam).  However, the VA C&P exam had normal ROM without pain on ROM measurement or repetition which could support a 0% rating.  

The Board adjudged that the MEB/PT exams were closest to the date of separation; best aligned with the disability picture in the preponderance of the record and therefore had the highest probative value for rating.  The Board agreed that a 10% rating, but no higher, was justified based upon limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) and painful motion.  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.  The Board considered whether additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had bulging discs with radicular pain, with symptoms of radiating pain documented in the treatment records; however, examinations indicated normal strength, reflexes and gait, and the sensory changes did not affect his job.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which impacted military occupation specific activities.  There is no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that additional disability rating was not justified on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 10% for the chronic back pain, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the chronic back pain, the Board unanimously recommends a disability rating of 10%, coded 5299-5237 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 medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Back Pain	5299-5237	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140525, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

JUL 19 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 XXXXXXXXXXXXXXXXXX, AR20160007631 (PD201402604)

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 10% 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