RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00287
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041007

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

CI CONTENTION:  The CI requested consideration of 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 -  20040722	VARD - 20041220	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical Low Back Pain…	5299-5237	10%	Mechanical Low Back Pain	5237	0%	20040910	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Mechanical Low Back Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began during basic training when he fell off of a wall.  Radiographic imaging studies were normal.  There was no surgical indication and despite conservative treatment to include medication, physical therapy (PT), and spinal manipulations, he could not be adequately rehabilitated to meet the physical requirements of his military specialty and was referred for an MEB.  The MEB forwarded “moderate constant, mechanical low back pain” for PEB adjudication.

The MEB NARSUM examination on 27 May 2004 (5 months before separation) noted complaints of constant non-radicular pain in the low back with occasional flare-ups, which were aggravated by exercise, bending, squatting, lifting heavy weights, or maneuvering stairs.  His physical examination (PE) revealed thoracolumbar spine tenderness with muscle spasms.  There was no comment regarding gait and or spinal contour parameters, and examination maneuvers for radicular signs were negative.  Thoracolumbar range of motion (ROM) was near normal (lacking 10 degrees of flexion) and painful at terminal limits.  At the 10 September 2004 VA Compensation and Pension (C&P) evaluation (1 month before separation), the CI reported constant and chronic lower back pain for the last 3 years.  His PE revealed no tenderness or muscle spasm in the lumbosacral area severe enough to result in an abnormal gait and examination maneuvers for radicular signs were negative.  Thoracolumbar ROM was normal.  The CI stated, “…condition does not cause incapacitation” and “There is no functional impairment resulting from this condition.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain), citing range of motion limited by pain, with localized tenderness.  The VA rated the back condition 0%, also coded 5237, based on the VA C&P examination 1 month before separation, citing a non-compensable evaluation.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) reported on the NARSUM examination.  The examinations noted the presence of muscle spasm, however, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

BOARD FINDINGS:  In the matter of the low back 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 20150429, 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, AR20160019826  (PD201500287)

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