RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03781
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20050405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Light Wheeled Vehicle Mechanic) medically separated for a back condition.   The back condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Mechanical low back pain was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated chronic low back pain without neurologic abnormality as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

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, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the 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/Naval 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 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:  

IPEB - Dated 20050128	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain w/o Neurologic Abnormality	5299-5237	10%	Disc Protrusion L5-S1	5242	0%	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3 	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20060109 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY: 

Low Back Pain without Neurologic Abnormality.  The CI initially presented with low back pain after a fall in December 2001.  He was treated with physical therapy, activity modification and pain medications.  He continued to report lower back pain and a magnetic resonance imaging study dated 3 November 2003 demonstrated lower lumbar and lumbosacral disc bulging.  The CI was treated with physical therapy, acupuncture and epidural steroid injection without pain resolution.  At the narrative summary examination performed 14 months prior to separation the CI reported persistent low back pain with intermittent radicular pain into both legs.  On physical examination there was lumbar tenderness to palpation and positive radiculopathy testing bilaterally.  Thoracolumbar motion was full except for extension which was limited to 15 degrees (normal 30).  A diagnosis of mechanical low back pain was rendered.  At a primary care visit on 7 March 2005, approximately a month prior to separation the CI reported persistent low back pain.  On physical examination there was lumbosacral tenderness to palpation, muscle spasm, a decreased range-of-motion (ROM) secondary to pain and pain with toe to heel walking. The CI did not present for a VA Compensation and Pension (C&P) examination.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition at 10% for local tenderness to palpation, coded 5299-5237 (analogous to lumbosacral strain).  The VA rated the condition 0% based on the service treatment records non-compensable ROM, coded 5242 (degenerative arthritis of the spine).  The Board considered whether the evidence supported a higher than 10% rating.  The Board noted a single primary care note that documented low back pain with physical findings of muscle spasms and an abnormal gait; however, the preponderance of treatment notes documented a normal gait and the absence of muscle spasm.  Board members agreed that the evidence did not support a higher rating.  The preponderance of evidence did not support an unfitting radiculopathy for additional ratings.   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 low back condition.  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the low 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.  

RECOMMENDATION:  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 20140820, 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, AR20160004326 (PD201403781) 

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