RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00133
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051007	

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:  The applicant contends his back condition is much more severe than how it was adjudicated by the military, and that he has since been found to be 100% disabled.  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 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 - 20050531	VARD - 20051121	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5235	10%	S/P Compression Fracture…	5235	10%	20050727	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back Pain.  The service treatment record (STR) indicated that the CI fell during obstacle course training in early 2004 and was first seen for low back pain (LBP) in June 2004.  A magnetic resonance image performed in October 2004 revealed a non-displaced fracture of L1 which was previously known to be present on plain X-rays performed 4 months earlier.  Additionally, there was degenerative disk disease (DDD) about the lower lumbar vertebra.  His condition was not considered for surgery and despite treatment including medication, manipulation, local injections, and restrictions, his back pain remained.  He was permanently profiled in March 2005 and referred to a Medical Evaluation Board (MEB). 
At the MEB narrative summary (NARSUM) examination (22 April 2005, 6 months prior to separation) the CI reported persistent LBP which did not allow him to conduct his duties.  His physical examination (PE) revealed thoracolumbar tenderness as well as decreased range of motion (ROM).  His diagnosis remained unchanged.  At the VA Compensation and Pension (C&P) examination (27 July 2005; 2 months pre-separation), the CI stated that “his condition does not interfere with his ordinary lifting or carrying, posture or gait.”  The PE was completely normal.  Although the provider noted the prior X-ray findings of degenerative arthritis as well as the old mild compression fracture, the final diagnosis was “status post trauma to back [by history].  No current pathology identified on PE to render a diagnosis.”  

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below. 

Thoracolumbar ROM
(Degrees)	MEB ~5 Mo. Pre-Sep
(20050503) 	VA C&P ~2 Mo. Post-Sep
(20050727) 	
Flexion (90 Normal)	(45) 45,46,45	90	
Extension (30)	(10) 9,7,7	30	
R Lat Flexion (30)	(25) 25,25,25	30	
L Lat Flexion (30)	(25) 22,24,24	30	
R Rotation (30)	(25) 22,23,24	30	
L Rotation (30)	(15) 15,16,16	30	
Combined (240)	145	240	
Comment	-	-	
§4.71a Rating	20%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated the back condition at 10% under VASRD code 5235 (vertebral fracture).  Board members first acknowledged the vast difference during the 7-month period between the NARSUM and VA ROM measurements and deliberated over examination probative value (PV) in this case.  After an extensive review of the STR, Board members concluded that exclusive PV is apportioned to the VA examination due to its close time reference to the date of separation.  The completely normal PE as found in the probative VA examination would not equate to any positive impairment rating under VASRD guidelines; therefore, IAW DoDI 6040.44, the Board may not recommend a rating lower than that received prior to application.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s 10% rating decision for the lumbar spine condition. 

BOARD FINDINGS:  In the matter of the LBP 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.   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 20140801, with attachments
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, AR20160014223 (PD201500133)

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