RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04165
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Chemical Operations Specialist, medically separated for “back pain” with a disability rating of 0%, citing EPTS [existed prior to service] and no service aggravation.

CI CONTENTION:  The CI requests consideration of 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 upon a 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 - 20030718	VARD - 20031028	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain	5299-5295	0%	Scoliosis Symptomatic …	5299-5295	10%	20030828	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in February 2002 after falling on several occasions while running on snow and ice in unit physical training.  Radiographic X-ray studies showed a mild lumbar scoliosis of 12 degrees from T10 to L4.  Despite treatment, the 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 symptomatic lumbar scoliosis for PEB adjudication.  During the MEB examination dated 2 April 2003, 6 months prior to separation, the CI reported a lower back pain radiating to her shoulders causing tightness of the muscles and numbness of her arms and legs.  The pain also caused trouble sleeping in any position.  The examination was reported as normal, including her back, skin, spine, and neurologic examinations.  The MEB NARSUM of 9 June 2003 (5 months prior to separation) noted complaints of chronic low back pain without radicular symptoms which gradually increased in frequency and severity.  The pain interfered with her activities of daily living, physical training requirements and her ability to perform the duties of her military specialty.  Physical examination revealed a full range-of-motion (ROM) of her lumbosacral spine with forward flexion of 90 degrees, extension of 30 degrees, and full rotation to the left and right.  At the 28 August 2003 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported upper and lower back pain.  Physical examination showed normal gait, normal station.  Flexion of the spine was to 90 degrees, extension 15 degrees, and right and left lateral flexion of 0 to 25 degrees.  The straight leg test raised to 90 degrees for both legs.  Knee and Achilles tendon reflexes were normal.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5295 code (Lumbosacral Strain), citing scoliosis as a congenital condition that EPTS, which was permanently service aggravated, but did not meet criteria for a minimum rating.  The VA assigned a 10% rating using an analogous 5295 code (Lumbosacral Strain) based on the VA C&P examination 1 month after separation, citing characteristic painful or limited motion.  There was characteristic pain on motion or limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine in effect at the time of separation.  The Board placed more probative value on the VA C & P examination and therefore after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board agreed that a 10% rating, but no higher, was justified for evidence of painful motion causing functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the back condition. 

BOARD FINDINGS:  In the matter of the back condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5295 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	
Back Pain 	5299-5295	10%	

The following documentary evidence was considered:

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

SAMR-RB										

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 AR20160018254 (PD201404165)

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 10% 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