RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00038
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Motor Transport Operator, medically separated for “low back pain [LBP],” with a disability rating of 10%.

CI CONTENTION:  The CI request consideration of 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 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 - 20030916	VARD - 20040205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LBP	5299-5295	10%	Lumbar Spine Degenerative Joint Disease with Disc Disease	5010-5237	20%	20030813	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

LBP.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in 1994 after falling on ice and then reinjuring the back in 1999 while lifting.  Radiographic studies on 23 July 2002 showed small endplate osteophytes from L2-3 to L4-5.  The disc spaces and alignment were intact and there was subchondral sclerosis of facet joints at multiple levels.  No pars defects were identified.  The impression was multiple levels of chronic disc and joint disease.  An MRI of the L-Spine on 24 October 2002 showed a normal study, with the conus terminating in its anatomic position.  A physical therapy note a week later on 30 October 2002 noted full active range of motion (ROM).  In pain management on 9 January 2003, a year prior to separation, the CI was noted to have reduced sensation over the left foot, but a normal motor and reflex examination.  Extension was reduced, but flexion was normal.  At a physical therapy appointment on 7 April 2003, the CI reported pain shooting up and down his left side, intermittently with walking.  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 “chronic back pain secondary to left sacroiliac joint pain syndrome” for PEB adjudication.  At the MEB examination dated 5 May 2003, 8 months prior to separation, the CI reported recurrent back pain on the left side with numbness or tingling and the use of a back support.  Physical examination showed tenderness to palpation (TTP) in the lumbar areas, left leg weaker than right, and diagnosed chronic LBP.  The MEB NARSUM examination on 16 April 2003, 9 months prior to separation, noted complaints of pain described as dull and sharp, as well as frequently burning.  The pain was worse depending on activity level.  The CI denied bowel or bladder incontinence, night sweats, fevers or unexplained weight loss.  The physical examination showed spinal contours grossly within normal limits except for mild flattening of the normal lumbar lordosis.  The MEB ROMs were for the lumbar spine rather than the thoracolumbar spine and measured in physical therapy on 12 May 2003 with an inclinometer (rather than a goniometer).  These were:  flexion 45 degrees (normal 90), extension 0 degrees (normal 30), right lateral flexion 30 degrees (normal 30) and left lateral flexion 10 degrees (normally 30).  Rotation, which is from the thoracic rather than lumbar spine, was not recorded as would be expected if only the lumbar spine was measured.  The normal values were for the thoraco-lumbar spine which exceed those limited to the lumbar spine.  The Board observed that a lumbar flexion of 45 degrees correlates with a thoraco-lumbar flexion of 75 degrees.  There was TTP over the left posterior superior spine that reproduced many of the CI’s back pain symptoms.  Straight leg raises (SLRs) to test for radiculopathy were negative.  He was intact to light touch and pinprick except for a relative loss over the left medial ankle and first web space on the left.  Strength was 5/5 bilaterally on all major lower extremity muscle groups.  Deep tendon reflexes were normal, as was Babinski response (test for disease of the spinal cord and brain).  At the 13 August 2003 VA Compensation and Pension (C&P) evaluation, performed 5 months before separation, the CI reported an 8-year history of back pain not responding to conservative treatment.  He endorsed pain most of the time and could walk 1-2 miles.  The physical examination showed a patient in no distress and with a normal gait.  ROMs referred to same MEB physical therapy measurements recorded above, SLR was negative, there was no muscle spasm or TTP over the spinal area and neurovascular status to the lower extremities was intact.  Strength was 5/5 and the CI was able to walk on his toes, heels and tandem walk.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB, using the VA schedule of ratings and disabilities (VASRD) applicable for the period through 25 September 2003, rated the LBP condition 10%, coded 5299-5295 (analogous to lumbosacral strain), citing pain with motion.  The VA rated the lumbar spine degenerative joint disease with disc disease condition 20% coded 5010-5237 (arthritis, due to trauma, substantiated by X-ray findings analogous to lumbosacral or cervical strain), based on the VA C&P examination 5 months before separation, citing decreased range of motion.  The limitation of forward flexion of the thoracolumbar spine motion 45 degrees to supports a 20% rating under the General Rating Formula for Diseases and Injuries of the Spine.  In this case, the LBP and the sacroiliac joint dysfunction are closely related conditions.  In accordance with VASRD §4.66 (sacroiliac joint) which stipulates “The lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes,” the Board considered the LBP and sacroiliac dysfunction together for fitness and rating determinations.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the LBP condition, coded 5099-5237  

BOARD FINDINGS:  In the matter of the LBP condition, the Board unanimously recommends a disability rating of 20%, coded 5099-5237 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	PERMANENT RATING	
LBP	5099-5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150112, 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, AR20160018789 (PD201500038)

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 20% 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