RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03490
BRANCH OF SERVICE:  Army	SEPARATION DATE: 20041103 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Army Reserve E-4, Automated Logistic Specialist, medically separated for low back pain (LBP) rated at 10%.  

CI CONTENTION:  The applicant has asked for consideration of all conditions in his application.  His 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 – 20040916	VARD	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Chronic Low Back Pain with Sacroliitis	5237	NSC	No Show	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  Service treatment records reflect that the CI initially reported lower back and right lower extremity radicular pain after a fall in January 2004.  The CI was treated with physical therapy, activity modification, sacroiliac injections, and medications.  At the time of the narrative summary (NARSUM) the CI reported persistent constant, sharp, lower back and right hip pain sleep difficulty secondary to pain, but denied right lower extremity radicular pain, weakness, and bowel or bladder changes.  The physical examination demonstrated an antalgic gait, lumbosacral tenderness to palpation, a palpable tender mass in the right sacroiliac joint, and positive testing for sacroiliitis.  Radicular pain testing was negative.  At the VA Compensation and Pension examination, 11 months after separation, the CI back pain was worse with bending, lifting, and repetitive use.  She denied incapacitating episodes and radicular pain.  The physical examination demonstrated thoracolumbar and sacroiliac tenderness to palpation and negative radicular testing.  The goniometric range-of-motion (ROM) evaluations 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)	MEB ~3 Mo. Pre-Sep
(20040820) 	VA C&P ~16 Mos. Post-Sep
(20051024) 	
Flexion (90 Normal)	90	70	
Extension (30)	20	25	
R Lat Flexion (30)	30	25	
L Lat Flexion (30)	30	25	
R Rotation (30)	28	25	
L Rotation (30)	15	25	
Combined (240)	#	#	
Comment	Decreased ROM due to pain, antalgic gait.	Pain at extremes of motion	
§4.71a Rating	20% ( 10% PEB)	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB and VA rated the condition at 10%, coded 5237 (lumbosacral strain).  The Board determined that the decreased ROM due to pain, lumbosacral tenderness to palpation, and an antalgic gait met criteria for a 20% rating.  There was no evidence of an unfitting radiculopathy or hip limitation of motion for additional disability ratings.  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 condition.  

BOARD FINDINGS:  In the matter of the lower back pain with sacroiliitis condition, the Board unanimously recommends a disability rating of 20%, 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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain with sacroiliitis	5237	20%	
COMBINED	20%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140623, with attachments
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 AR20160008177 (PD201403490)

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