RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00335
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061113

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

CI CONTENTION:  The CI contends residuals from his unfitting condition merit review.  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 - 20060821	VARD - 20071012	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	0%	Degenerative Disc Disease, Lumbar Spine	5010	10%	20070425	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain condition began in November 2003 during physical training (PT).  X-rays of the spine in November 2003 revealed spina bifida occulta (developmental defect of spine) of the L5 segment and decreased space between L5-S1.  The CI had no further indications of back pain until he required a medical clearance for entry into the US Army Military Academy (USAMA) in February 2005.  He denied back pain and was referred for radiographic evaluation and orthopedic evaluation.  Magnetic resonance imaging (MRI) of the lumbar spine in February 2005 revealed anatomic alignment of the vertebrae and body height within normal limits. There was mild L4-5 disc degeneration and a congenitally small central canal with a small right lateral L5-S1 disc herniation possibly compromising the exiting right S1 nerve and a central L4-5 disc herniation without neural compromise.  Orthopedic evaluation noted the CI complained of 100% back pain with no radiation.  The CI denied bowel or bladder symptoms; however, pain worsened when bending or lifting and was relieved with Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)).  Physical evaluation on 22 February 2005 revealed a straight non-tender spine, negative straight leg raises (SLR) (to determine nerve root irritation), and negative FABER (provocative test for pain) tests, symmetrical reflexes, bilateral motor 5/5 strength, and sensation intact to light touch.  The range of motion (ROM) forward flexion was to 12 inches with limited extension.  The examiner stated the symptoms significantly interfered with his athletic activities.  In April 2005 a note indicated the CI had chronic low back pain without radiculopathy or neurologic symptoms.  A note in November 2005 indicated the CI had gained 35-40 pounds since December 2004 and was doing crunches four times a week.  

Despite treatment including physical therapy, medication, and epidural steroid injections (ESI’s), the CI’s back condition could not be adequately rehabilitated to meet the physical requirements for training and he was referred for a Medical Evaluation Board (MEB).  The MEB forwarded “chronic low back pain; L4/5 & L5/S1 intervertebral disk protrusion; and spinal bifida occulta” for PEB adjudication.

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	MEB ~8 Mo. Pre-Sep
(20051216) p.38	VA C&P ~5 Mo. Post-Sep
(20070405) p.312	
Flexion (90 Normal)	(50)72,68,50*	90	
Extension (30)	(30)35,36,35	30	
R Lat Flexion (30)	(30)38,41,42	(30)35	
L Lat Flexion (30)	(30)40,45,43	(30)35	
R Rotation (30)	(30)51,55,52	(30)35	
L Rotation (30)	(30)55,57,57	(30)35	
Combined (240)	200	240	
Comment	*No comment on the 3rd flexion repetition in the record	Painful motion; no loss of motion on repetition	
§4.71a Rating	20%	10%	

At the MEB examination in March 2006, 8 months prior to separation, the CI reported his herniated disc caused pain and he was evaluated for surgery.  Physical examination revealed pain with spinal flexion and negative straight leg raising.  The MEB NARSUM examination on 3 March 2006, 8 months prior to separation, noted complaints of continued back pain which was treated conservatively.  Physical examination ROM measurements were flexion of 72, 68, and 50 degrees (normal 90) after repetition.  He had negative radicular symptoms and SLRs and denied bowel and bladder symptoms.

Post-separation X-rays in March 2007 demonstrated mild narrowing of L1-2 and L5-S1 disc space and some spina bifida occulta was seen at L5.   At the 5 April 2007 VA Compensation and Pension (C&P) Spine evaluation, performed 5 months after separation, the CI reported his pain had progressively worsened and he still used conservative measures (physical therapy, occupational therapy and pain medication) for treatment resulting in a fair response.  Physical examination showed no spasms, atrophy, guarding, or weakness.  Bilateral pain on motion and tenderness were noted, but not severe enough result in an abnormal gait or spinal contour.  Flexion was 90 degrees with pain on motion; the remainder of the ROMs are in the chart.  Neurologic evaluation was unremarkable.   
The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 0%, coded analogously 5299-5237 (Lumbosacral strain), citing painful motion.  The VA rated the back condition 10% coded 5010 (Arthritis, degenerative), based on the VA C&P examination 5 months after separation, citing painful motion.

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 MEB NARSUM, albeit with the third repetition at 50 degrees.  Board members considered whether the precipitous drop of flexion to 50 degrees from 72 degrees and 68 degrees should be taken at face value since it was inconsistent with antecedent flexion measurements in the absence of painful motion or any other reasonable observation or explanation.  A 10% rating is further supported by the VA C&P examination, which was more proximate to separation with a 90 degrees flexion and painful motion, which is consistent with the VA rating using code 5010 or an analogous code 5099-5003.  There was no muscle spasm or guarding 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 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 condition, coded 5243 (intervertebral disc syndrome) because of herniated discs at L4-5 and L5-S1.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5243 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	5243	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150527, 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

21 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018682 (PD201500335)

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