RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03711
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050613

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Heavy-Wheeled Vehicle Mechanic, medically separated for “chronic low back pain with findings of L5/S1, spondylolysis and spondylolisthesis, following MVA in Mar 04,” with a disability rating of 10%.  

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 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 - 20050331	VARD - 20050629	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5239	10%	Degenerative Disc Disease, Lumbar Spine	5237	10%	20050527	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

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 March 2004 after a motor vehicle accident.  Radiographic studies showed spondylolysis and spondylolisthesis (L5 pars defect of the vertebral wing and slippage of alignment).  Despite non-surgical treatment, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of his military specialty and so he was referred for an MEB.  The CI elected MEB rather than an offered surgical stabilization option.  

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)	MEB ~7 & 12 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (90 Normal)	“Full range of motion”	70	
Combined (240)		180	
Comment	Tenderness and spasm	Tenderness and spasm; “antalgic gait secondary to knee pain”	
§4.71a Rating	10%	10%	

At the MEB examination (recorded on DD Form 2807 and 2808) dated 8 November 2004, 7 months prior to separation, the CI reported that his back pain was getting worse, but did not radiate.  He also reported that his legs would go numb and that he had tingling, but that was not a common symptom.  Physical exam indicated that he had a normal spine.  At the MEB NARSUM dated 21 November 2004 (7 months prior to separation), referenced an exam dated 18 June 2004 (12 months prior to separation).  The examiner recorded that rest, oral medications, restricted duties, and chiropractic manipulations had failed to relieve his ongoing back pain.  Physical exam showed positive tenderness and spasm, but did not discuss his gait or spinal contour.  He was noted to have normal strength, sensation, coordination, and reflexes with full ROM as indicated in the chart above.  

At the VA Compensation and Pension (C&P) examination on 27 May 2005, performed a month before separation, the CI reported that his back pain was worse with walking, lifting, bending, and running. Physical exam showed limitation of motion as indicated in the chart above with positive tenderness and spasm.  He had an antalgic gait, but it was due to knee pain.  He also had normal strength.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5239 code (spondylolisthesis or segmental instability), citing muscle spasm and tenderness to palpation.  The VA also assigned a 10% rating using the 5243 code (intervertebral disc syndrome) based on the VA C&P examination a month before separation, citing limitation of flexion.  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 as noted on the VA exam or for the presence of tenderness to palpation or muscle spasm reported on the NARSUM and  VA exams.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  

Although the CI experienced episodic numbness and tingling into the legs, there was no objective evidence of a radiculopathy or functional impairment with a direct impact on fitness.  There is no evidence in this case that there was radiculopathy with associated functional impairments separately functionally impairing.  The Board therefore concludes 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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, 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 20140605, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		

SAMR-RB

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160009323 (PD201403711)

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