RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00009
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050503

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Automated Logistics Specialist, medically separated for “chronic thoracolumbar back pain,” with a disability rating of 0%.

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 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 - 20050222	VARD - 20051207	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain…With Spondylolysis of L5/S1	5299-5237	0%	Bilateral L-5 Spondylolysis and DJD T10-T11	5242	20%	STR	
Acne	Not Ratable	Acne	7828	NSC	
Depressive Disorder	Not Unfitting	Depression	9434	NSC	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in September 2003 after heavy lifting.  Radiographs showed bilateral spondylolysis of L5 and mild narrowing of L5-S1, and degenerative joint disease at T10 and T11.  He was not a surgical candidate.  Despite treatment, the CI’s condition did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “back pain secondary to bilateral L5 spondylolysis and degenerative joint disease at T10 and T11” for PEB adjudication.

The MEB NARSUM examination on 15 December 2004, 5 months prior to separation, noted complaints of constant burning pain in the thoracic spine, with sharp pains in the lumbar spine rated 6/10, that worsened with lifting more than 10 pounds or standing in place for more than 2 minutes.  The pain improved with lying down, ice, and pain medications.  

Physical examination showed there was mild paraspinous muscle tenderness and minimal tenderness to the thoracic spine.  Straight leg raising was normal.  Range of motion (ROM) of the lumbar spine recorded flexion of 80 degrees after repetition (normal 90) and extension of 25 degrees (30 normal), both limited by pain.   Muscle strength, reflexes and sensation were all normal.  Muscle spasms were not recorded.  

The VA, using STR’s rated the back condition 20% citing “muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded analogously 5237 (lumbosacral strain) citing motion limited by pain.  The VA granted a 20% rating, coded 5242 (degenerative arthritis of the spine) citing “ongoing complaints of severe pain and muscle spasms requiring daily Oxycodone.”  The higher 20% rating under the general spine codes requires spasms producing abnormal gait, or abnormal curvature of the spine, or forward flexion greater than 30 but not greater than 60 degrees.   

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) reported on the NARSUM examination.  The CI reported muscles spasms, but after a thorough review of the STR there was no objective evidence of muscles spams or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS). There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an 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 recommends a disability rating of 10%, coded 5237 for the chronic low back pain condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the Acne, grade II, depressive disorder, NOS, and Cluster B personality traits conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the thoracolumbar condition, the Board recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the contended Acne Grade II, Depressive Disorder, NOS, and Cluster B personality traits conditions, the Board recommends no change from the PEB determinations as not unfitting.  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	PERMANENT RATING	
Thoracolumbar Back Pain	5299-5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141208, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160018463 (PD201500009)

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