RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2015-00258
BRANCH OF SERVICE: Army	SEPARATION DATE:  20040409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2, Trainee, medically separated for “low back pain,” with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention.  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 - 20040318	VARD -20061205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Chronic Strain, Lumbar Spine W/Minimal Limitation of Motion	5237	10%	20061010	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back Condition.  According to Service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI experienced acute onset of mid to low back pain during the first week of advanced individual training (AIT) in September 2003.  At a 6 September 2003 physical therapy (PT) evaluation, the CI complained of 2 weeks of increasing low back pain (LBP).  The physical examination revealed lumbar paraspinal muscle tenderness and hamstring tightness.  Lumbar range of motion (ROM) was full.  The straight leg raise ([SLR] assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) and flexion, abduction, external rotation, and extension ([FABERE] assesses hip and sacroiliac joint pathology) tests were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  Back diagnostic imaging studies in October 2003, which included X-ray, MRI, and bone scan, were normal.  A 19 December 2003 orthopedic surgery encounter documented the CI was doing very well and was much improved with daily PT.  The physical examination documented standing with a normal posture and fully erect.  Back ROM was flexion to the knees ~45-60 (90 normal), extension of 20 (30), and bilateral side bending of 30 (30) degrees.  The 25 February 2004 NARSUM, 2 months before separation, reported a history of sudden onset of mid to low back pain during the first week of AIT.  There was some radiation of pain and paresthesias (abnormal sensation, tingling, burning, prickling) to his left lower extremity and great toe for the first 4 weeks.  The CI experience incomplete relief of symptoms with conservative management (activity modification, PT, electrostimulation, chiropractic care, and anti-inflammatories).  He reported improved function, waxing and waning pain 75-100% of waking hours, and some interference with sleep.  The CI denied return of lower extremity symptoms after the first 4 weeks or bladder dysfunction or incontinence.  The physical examination documented walking with an upright posture and non-antalgic (assuming a gait or posture to lessen pain) gait.  The back examination revealed midline tenderness between T12 and L4 and some muscle paraspinal spasm.  Back ROM was flexion to just below the knees ~45-60 (90 normal), extension of 20 (30), bilateral side bending of 30 (30), and bilateral rotation of 30 (30) degrees.  The SLR and FABERE tests were negative.  Strength, sensation, DTRs, and pulses were normal.  Waddell’s signs (psychogenic, or nonorganic, manifestations of pain) were 2/5 (1 = distraction, 1 = reaction).  The examiner recounted the findings of the X-rays, MRI, and bone scan.  The diagnosis listed mechanical LBP.  The 10 October 2006 compensation and pension (C&P) examination documented a normal gait.  The spine examination revealed tenderness with no muscle spasm, atrophy, guarding, weakness, or abnormal spinal curvature.  Pain-limited thoracolumbar spine active ROM was flexion of 80 (90), extension of 30 (30), bilateral lateral flexion of 30 (30), and bilateral rotation of 30 (30) degrees.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The diagnosis listed chronic lumbar spine strain with minimal limitation of motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (lumbosacral strain) citing LBP, tenderness, spasm, decreased ROM, Waddell signs of 2/5, and no focal neurological deficit.  The VA assigned a 10% rating under the 5237 code (lumbosacral strain) based on the VA C&P examination, citing chronic lumbar spine strain, tenderness, pain with motion, minimal limitation of ROM, normal X-rays, posture, gait, strength, and sensation and no abnormal spinal curvatures, ankylosis, spasm, atrophy, guarding, or weakness.  The VA C&P ROM values were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  The higher 20% rating would require (flexion of greater than 30 degrees but not greater than 60 degrees; or a combined ROM of not greater than 120 degrees of the thoracolumbar spine).  The ROM values in the orthopedic surgery and MEB exams were consistent with the 20% rating.  While the CI complained of radiation of pain and paresthesias to his left lower extremity in the initial first 4 weeks, these symptoms resolved without recurrence.  There was no evidence that motor weakness or sensory impairment existed to any degree that could be described as functionally impairing.  The Board therefore concluded that additional disability rating was not justified on this basis.  There was no documentation of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  While the proximate examinations documented tenderness and muscle spasm, there was no evidence of abnormal spinal contour or abnormal gait.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  
 
BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the Board majority 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 20150530, 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, AR20170002580 (PD201500258)

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