RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03056
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030328

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Field Artillery Surveyor, medically separated for “chronic low back pain,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 based on 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 - 20030211	VARD - 20031204	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5293-5299-5295	10%	Chronic Low Back Pain	5292	10%	20030527	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in October 2000 with a reinjury noted in August 2001 after a “home injury.”  Six primary care visits in Fall 2001 and Spring 2002, examiners documented “full” or “good” range of motion (ROM) (at 4 visits); no spasms (at 3 visits); and a normal gait (at 1 visit).  One visit documented “decreased” ROM (without specific measurements) and there was inconsistent documentation of tenderness.  There was no documentation of episodes of incapacitation requiring physician prescribed bed rest and no documentation of radiculopathy.  At the MEB examination (recorded on DD Form 2807 and 2808) dated June and July 2002, respectively (9 and 8 months pre-separation), the CI reported recurrent back pain with numbness and tingling.  Physical exam showed forward flexion of 90 degrees (normal) with normal extension, and lateral bending.  There was normal sensation and strength with no spasm or deformity.  The MEB NARSUM examination was performed on 2 January 2003 (3 months prior to separation).  The CI reported intermittent pain triggered by walking more than a mile, running, repeated bending, heavy lifting, or sitting for more than 30 minutes.  Physical examination showed flexion to 90 degrees, with normal extension, and normal lateral flexion and rotation bilaterally.  There was normal sensation and strength with no spasm or deformity.  

At the VA Compensation and Pension (C&P) examination in May 2003 (2 months after separation), the CI reported constant pain rated 6-7/10 which made it difficult to get up in the morning.  Physical exam showed a normal gait, with normal flexion and bilateral rotation.  There was no tenderness and no significant changes after repetition.  

The Board directed attention to the rating recommendation based on the above evidence.  The Reconsideration PEB assigned a 10% rating, analogously coded 5293-5299/ 5295 (intervertebral disc syndrome; lumbosacral strain) citing painful but functional range of motion.  They considered an underlying congenital deformity as EPTS and “rated for permanent service aggravation;” however, no deduction was imposed.  The VA also assigned a 10% rating, analogously coded 5292 (spine, limitation of motion of, lumbar) based on the VA C&P examination 2 months after separation, citing pain with slight limitation of motion.  At the time of separation in March 2003, the 2003 standards for rating based on ROM impairment were subject to the rater’s opinion regarding degree of severity; whereas, the current standards specify rating thresholds in degrees of ROM impairment.  When older cases have measurements in evidence, the Board reconciles (to the extent possible) its opinion regarding degree of severity for the older spine codes.  

The Board considered the evidence for the back condition using the 2003 VASRD.  In consideration of the 5292 code (spine, limitation of motion of, lumbar), only one examination documented “decreased” ROM without comment as to the severity.  All other examinations documented “full” ROMs.  Therefore there was no evidence to support a higher than 10% rating.   The Board next considered code 5293 for intervertebral disc syndrome which required quantification of incapacitating episodes and this information was not in evidence for the Board’s review.  There was no mention of any missed work days or bed rest, only the inability to perform his full MOS.  The Board also considered code 5295 for lumbosacral strain.  The CI reported painful motion, however there was no evidence of abnormal gait, spasm on extreme forward bending, significant loss of lateral spine motion in the standing position and no evidence that would be considered as “moderate” in support of a higher rating.  None of these coding options afforded a greater than 10% rating advantage to the CI.  Although occasional radiating pain and subjective numbness were reported prior to separation, there were no objective neurologic abnormalities.  There was insufficient evidence to indicate impairment of duty due to any radiculopathy.  The Board therefore adjudged that there was insufficient evidence to warrant any additional rating for radiculopathy.  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 low back pain condition.  

BOARD FINDINGS:  In the matter of the low back condition and IAW the 2003 VASRD, 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 20140624, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160013896 (PD201403056)

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