RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00227
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040710

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

CI CONTENTION:  “Review all records.”  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 - 20040527	VARD - 20041104	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain 	5299-5237	10%	Lumbar Paravertebral Myositis, Lumbar Degenerative Changes, Disc Discogenic Disease with Associated Herniated Disc	5243-5237	20%	20040922	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain (LBP) began in April 2003 after changing a tire.  A magnetic resonance imaging (MRI) performed on 24 September 2003 revealed lumbosacral degenerative disc disease (DDD) with multi-level disc bulge/protrusion without nerve root impingement or spinal stenosis.  Electro-diagnostic studies performed on 29 April 2004 were negative for radiculopathy.  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 MEB.  The MEB forwarded “slight frequent chronic LBP and left leg radiculopathy due to DDD of lumbar spine” for PEB adjudication.  At the time of a primary care clinic evaluation on 08 April 2004, the examiner recorded the CI walked normally and was in no acute distress.  On physical examination, the CI demonstrated lumbar tenderness.  Thoracolumbar range of motion (ROM) with regards to flexion was documented as “unable to reach the floor within eight inches,” which approximates 70+ degree range (normal 90).  His extension was 20 degrees (normal 30) and his bilateral lateral flexion was normal.  Painful motion was present.  

The MEB NARSUM examination on 22 April 2004, 3 months prior to separation, noted complaints of chronic LBP and radicular symptoms down the left leg.  Physical examination revealed tenderness without spasms about the lumbar spine.  There was decreased light touch sensation over the front portion of the left thigh and hip.  Radicular examination maneuvers were highly sensitive for a radiculopathy/neuropathy on the left side versus the right side, which was moderately sensitive.  Thoracolumbar ROM measurements revealed painful and decreased flexion at 65 degrees and extension to 15 degrees.  

At the 22 September 2004 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported continued severe and intermittent LBP associated with left thigh numbness.  He also endorsed weekly flare-ups whereby he reports “limits his ability to perform standing from sitting.”  The examiner noted the CI demonstrated “muscle spasms and reverse lordosis (abnormal lumbar spine curvature),” as well as a normal gait.  His thoracolumbar ROM measurements were painful, but normal, except for 60 degrees of forward flexion without evidence of fatigue, weakness, or lack of endurance upon repetition.  Sensory and strength testing were normal.  There was evidence of radicular tenderness into the left buttock and mid-thigh.  

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA utilized the same primary VASRD code of 5237 (lumbosacral strain) and the PEB rated the condition at 10% and the VA assigned a 20% rating, respectively, citing painful motion by the PEB and limited motion by the VA.  All Board members agreed that a 20% rating, but no higher, was justified for muscle spasm severe enough to result in abnormal spinal contour as reported on VA C&P examination 2 months after separation.  

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 a separately unfitting peripheral nerve impairment which would provide for additional rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” Electro-diagnostic studies proximate to separation did not show evidence of radicular nerve irritation or involvement, and physical examinations performed proximate to separation revealed no objective findings of radiculopathy that would adversely impact duty performance.  The preponderance of evidence near the time of separation showed there was no objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that was separately functionally impairing for duty.  The Board therefore concluded that 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 20% for the chronic low back pain condition, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5299-5237 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	
Chronic Low Back Pain	5299-5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150312, w/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

21 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018542 (PD201500227)

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