RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03262
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060512

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Heavy Equipment Operator, medically separated for “chronic low back pain secondary to multilevel degenerative disc disease,” with a disability rating of 0%.   

CI CONTENTION:  “Please 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 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 – 20060321	VARD - 20060525	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5237	0%	Lumbar Spine Central Disc Protrusion with Degenerative Disc Height of L5-S1 and Right Leg Radiculopathy 	5237-5010	10%	20051228	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in 2003 without any specific injury or trauma.  At the time of the physical therapy appointment on 9 August 2004, the examiner noted the absence of muscle spasm; however, the CI experienced decreased sensation of the right lower extremity, and forward flexion was to three inches from the floor.  At an orthopedic examination on 9 June 2005, the CI noted continued pain radiating to his thigh and calf.  The examiner reported a reduced lordotic (anterior spine curvature) curve with forward flexion of the CI being able to touch his ankles and a normal interpretation of diagnostic imaging.  Magnetic resonance imaging on 10 July 2005, showed a small disc protrusion at L4-5, probably contacting the left side root and degenerative disc height reduction at L5-S1.  In August 2005, the CI underwent a right sacroiliac (SI) joint injection with steroid and local anesthetic with no relief.  At Physical Medicine on 13 December 2005, the CI complained of low back pain radiating to both legs (R>L), right leg weakness and right thigh and calf numbness.  Despite treatment, the low back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “degenerative disc disease L5-S1” and “disc bulge, central disc protrusion at L4-5” for PEB adjudication.

At the 28 December 2005 VA Compensation and Pension (C&P) evaluation, 5 months before separation, the physical examination showed a normal posture and gait and a lumbar flexion of 35 degrees (90 normal) and a combined range of motion (ROM) of 105 degrees (240 normal), limited by pain.  

The 4 January 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain radiating to his right thigh.  Physical examination showed a normal spinal contour and lower extremity sensation.  Thoracolumbar ROM was recorded as flexion of 85 degrees and combined ROM of 205 degrees, limited by pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back condition 0% coded 5237 (lumbosacral strain), citing slightly restricted ROM due to pain alone.  The VA rated the low back condition 10% coded 5237-5010 (lumbosacral strain-arthritis, due to trauma), based on the VA C&P examination 5 months before separation, citing painful motion.  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 NARSUM examination.  The Board assigned more probative value to the NARSUM examination because it measured repetitive (X3) thoracolumbar spine ROM values versus the solitary lumbar spine ROM values documented in the C&P examination.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under the formula for IVDS.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an additional disability rating was not justified on this basis.  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 10% for the chronic low back pain condition, coded 5237.  

BOARD FINDINGS:  In the matter of the chronic low 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	RATING	
Chronic Low Back Pain 	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140515, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR2016001132i , XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board's recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the
outcome you may have desired.

This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your applicatlon, XXXXXXXXXXXXXXXXXXX.

Sincerely,

Enclosure