RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00250
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040317

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Laundry and Textile Specialist, medically separated for “chronic back pain without neurologic abnormality,” with a disability rating of 10%.  

CI CONTENTION:  The CI requests the Board 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 – 20040202	VARD - 20040825	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain without Neurologic Abnormality	5299-5237	10%	Chronic Low Back Pain	5237	0%	20040530	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 0%	

ANALYSIS SUMMARY:  

Low Back Pain without Neurologic Abnormality.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in May 2002 after lifting a heavy generator.  Magnetic resonance imaging (MRI) studies of the lumbar and thoracic spine on 12 May 2003 showed no abnormalities.  Lumbar spine X-rays in October 2003 were also normal.  At the orthopedic appointment on 5 November 2003, the CI reported persistent low back pain with no improvement.  On examination, range of motion (ROM) was “90%” of normal.  There were no motor, neurological, or sensory deficits.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.  The MEB forwarded “chronic upper, mid and low back pain, muscular etiology” for PEB adjudication.  At the MEB examination on 5 January 2004, tenderness of the left thoracic paraspinal muscles was noted.  The 5 January 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of pain in the low back up to his neck which continued to worsen and limited his ability to perform his military duties to include physical training.  On examination the straight leg raise (SLR) tests (assesses for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative and there were no motor or sensory abnormalities.  Thoracolumbar ROM was flexion of 55 (normal 90) and a combined ROM of 175 (240 normal) degrees.  The examiner was silent regarding gait, spasm, tenderness, and spinal contour.  At the 30 May 2004 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported daily pain, rated at 8/10.  The CI reported he was able to walk 3 miles.  Physical examination showed a normal gait and no motor or sensory loss.  Thoracolumbar ROM was flexion of 95 (90 normal) and combined ROM of 240 (240 normal) degrees after repetition, with no pain during or after repetition.  There were no radiating symptoms. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5237 code (lumbosacral strain), citing combined ROM of 175 degrees.  The VA assigned a 0% rating using the 5237 code (lumbosacral strain) based on the VA C&P examination 2 months after separation, citing full ROM without pain.  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the NARSUM exam.  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 low back condition, coded 5237.  

BOARD FINDINGS:  In the matter of the back condition, the Board unanimously recommends a disability rating of 20%, coded 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 to medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Back Pain Without Neurologic Abnormality	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150317, 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

21 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018556 (PD201500250)

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