RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03245
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070727

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 a back injury, with a disability rating of 0%.

CI CONTENTION:  The CI requests the Board consider all conditions.  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 - 20070529	VARD - 20080428	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Injury	5237	0%	Multi Disc Protrusions (T3 Through T9) and Anterior
Vertebral Wedging (T8 Through Tl 1)	5237	20%	20080325	
Anxiety	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY: 

Back Injury. According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in October 2005 after falling off an obstacle during training and landing on a stump on his back.  Radiographic studies (December 2006, April 2007, 3 and 6 months prior to separation) conclude normal cervical spine and normal lumbar spine.  There was no surgical indication.  
Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded post traumatic multiple thoracic spine disc protrusions contacting the cord to the PEB.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated April 2007, 3 months prior to separation, the CI reported chronic upper and mid back pain with extremity (upper and lower) neuropathic pain and radiculopathy.  The NARSUM physical examination showed the back was normal to inspection and palpation.  There was some reproduction of back pain with axial loading.  Normal gait, normal stance and smooth movements were noted.  Flexion was decreased to 75 degrees (normal 90) and extension to 25 degrees (normal 30).  At the VA Compensation and Pension (C&P) examination in March 2008, performed 8 months after separation, the CI reported that pain increases with certain activities and he cannot stand more than 10 minutes at a stretch and cannot sit more than 1 to 2 hours.  Physical examination showed the CI can stand erect without support with minimal tenderness present over the mid thoracic spine from T6 through T9 and no obvious deformities of the thoracic spine.  Also noted were no paraspinal muscle spasms and no tenderness or paraspinal spasm over the cervical spine or the lumbosacral spine.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the analogous 5237 code (Lumbosacral Strain), citing flexion limited by pain.  The VA assigned a 20% rating using the analogous 5237 code based on the VA C&P examination 8 months after separation, citing limitation of forward flexion.  Based on the evidence from the MEB NARSUM (within 3 months of separation) the ROM showing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, supports a rating of 10%.  There is no evidence or alternate code to support a higher rating than the Boards rating recommendation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the back condition, coded 5237 IAW VASRD §4.71a.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that “anxiety” was not unfitting.  The anxiety condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for contended conditions and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition, the Board unanimously recommends a disability rating of 10%, coded 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	
Back Injury	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140423, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record
SAMR-RB										

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 XXXXXXXXXX, AR20160011469 (PD201403245)

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