RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00254
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041208  

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

CI CONTENTION:  “Higher military rating sought.”  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 - 20040920	VARD - 20050308	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	0%	Thoracolumbar Lumbago	5237	10%	20041110	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began in February 2003 after a fall on the sacrum.  The NARSUM indicated a fall during deployment in October 2003 and a note dated 15 November 2003 referred to a fall 2 months earlier. A chest X-ray in December 2003 showed a sharply marginated, rounded nodular density suspected to be a bone island in T4, but no evidence of fracture or degenerative changes compared to a normal chest X-ray in March 2003.  There was no surgical indication, and conservative treatment, including physical therapy, chiropractic manipulation, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants, did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded lumbago for PEB adjudication.  The MEB NARSUM examination on 3 August 2004, 4 months prior to separation, noted complaints of back pain the CI treated with NSAIDs and a muscle relaxant.  Physical examination showed tenderness of the spine muscles and “decreased ROM” with no specific measurements provided.  At the time of the physical therapy appointment on 26 August 2004, the CI reported low back pain rated 6/10 in severity.  Range of motion (ROM) measurements of flexion were 64/65/62 degrees (normal 90) and the combined ROM was 145 degrees (normal 240) without pain.  

At the 10 November 2004 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the ROM measurement was 70 degrees flexion with a combined ROM of 130 degrees.  Only one iteration of ROM could be performed due to pain.  Provocative testing for nerve root impingement were negative and reflexes were normal.  In September 2005, 9 months after separation, the CI was able to forward flex approximately 45-60 degrees and laterally rotate to about 40 degrees bilaterally; however, he did report being in an altercation without any further details.  At an emergency room visit on 30 September 2005, he reported he fell out of bed and examination revealed a normal gait with no tenderness over the spine, but some muscle spasm in the muscular areas of his back diffusely.  An X-ray series of the thoracic spine on 30 September 2005 was normal, while X-rays of the lumbar spine suggested a minimal compression fracture of the superior anterior plate of L3 and possibly L2.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain 0%, coded 5237 (lumbosacral strain), citing chronic back pain.  The VA also used the 5237 code, but rated the back condition 10%, based on the VA C&P examination, citing limitation of motion.  The Board agreed a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the VA examination, which was more proximate to date of separation.  Flexion as measured at the 26 August 2004 physical therapy examination was rounded to 60 degrees; nevertheless actual measurements were greater than 60 degrees, although the examination was 3 months prior to separation compared to the VA examination, 1 month prior to separation.  There were no muscle spasms or guarding severe enough to result in an abnormal gait or spinal contour for a 20% rating.  Board members considered the approximate measurements of flexion (45-60 degrees) 9 months after separation and with the absence of more precise measurement, as well as scant details of whether an injury occurred as a result of the “altercation” or any other event, there was little to no probative value of that examination for rating purposes.  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 10% for the chronic back pain, coded 5237.  

BOARD FINDINGS:  In the matter of the chronic back pain, the Board unanimously recommends a disability rating of 10%, 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 medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Back Pain	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150226, 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 
XXXXXXXXXXXXXXXXXX, AR20160019813 (PD201500254)

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