RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03754
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Unit Supply Specialist, medically separated for “chronic back pain due to L5-S1 spondylolisthesis without neurologic abnormality,” rated at 10%. 

CI CONTENTION:  The CI requests the Board consider all conditions.  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 - Dated 20040225	VARD - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain due to L5-S1 Spondylolisthesis Without Neurologic Abnormality	5239	10%	Degenerative Disc Disease 
and Spondylolisthesis of the
Lumbar Spine	5239-5243	20%	STR	
RATING:  10%	RATING:  20%	

ANALYSIS SUMMARY:  

Chronic Back Pain due to L5-S1 Spondylolisthesis without Neurologic Abnormality.  At a primary care visit dated 2 July 2003, the CI reported a 3-year history of lower back pain.  He described the pain as tense with walking and sitting.  The examiner documented full range of motion (ROM), slight curvature and no tenderness to palpation.  An orthopedic note dated 9 July 2003 documented a diagnosis of spondyl	olisthesis at the lumbosacral junction.  The CI was referred to physical therapy.  On 20 October 2003, the CI presented with 7/10 lower back and bilateral posterior thigh pain.  A magnetic resonance imaging (MRI) study demonstrated degenerative disc changes at the lumbar level 5 (L5), a pseudo-disc with impingement of the L5 nerve root.  The CI was treated with activity modification and pain management.  The narrative summary (NARSUM) examination performed 3 months prior to separation noted left lumbar muscle spasms, tenderness to palpation, positive radicular testing on the left, and difficulty maintaining balance with heel-to-toe walk.  There were no VA examinations 12 months proximate to separation within the available evidence.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	PC ~10 Mo. Pre-Sep	PT ~3 Mo. Pre-Sep	
Flexion (90 Normal)	Full ROM	90	
Extension (30)		7	
Combined (240)		210	
§4.71a Rating	0%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5239 (spondylolisthesis).  The VA rated the condition 20%, coded 5239-5243 (spondylolisthesis-degenerative disc disease).  The Board considered whether the evidence supported a higher than 10% rating.  Several treatment records documented recurring episodes of severe back pain.  The NARSUM documented muscle spasms and difficulty with balance performing heel to toe walk, but no documentation of gait abnormality.  Board members agreed that the evidence supported a 10% rating for muscle spasm not resulting in an abnormal gait.  There was no evidence of an abnormal gait or forward flexion of less than 60 degrees or other criteria for a higher rating.  Board members agreed that the evidence did not support an unfitting radiculopathy for additional disability rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board agreed that a disability rating of 10% for the back condition was appropriately assigned.  

BOARD FINDINGS:  In the matter of the chronic back pain due to L5-S1 spondylolisthesis without neurologic abnormality and IAW VASRD §4.71a, the Board 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 20140730, 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 XXXXXXXXXXXXXXXXXX, AR20160009338 (PD201403754)

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