RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00337
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Medical Laboratory Specialist, medically separated for “chronic low back pain” 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 - 20061018	No VA Rating Decision in evidence	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5235	10%					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in May 2005 after a fall negotiating an obstacle course.  Radiographic studies showed an L1 compression fracture.  Despite treatment and 3 months of convalescent leave, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.  The MEB forwarded “chronic low back pain” for PEB adjudication.  The MEB NARSUM examination on 5 September 2006, 5 months prior to separation, noted complaints of pain in her “buttock and (sacroiliac) SI joints.”  The major portion of pain was in the SI joint and did not radiate.  Her condition was aggravated with sitting or standing for prolonged periods of time.  Physical examination showed guarded movements as she moved “her back slowly and with care,” but the examination was silent in regards to abnormal spinal contour or gait.  Her range of motion (ROM) was decreased in all planes of movement and during forward flexion, she could only reach her fingertips to the bottom of her thighs.  The actual ROM measurements were not included in the examination.  There was no tenderness to palpation of her back.  Testing for radicular pain was negative and she had normal motor strength, sensation and reflexes.  The examination was silent on the disc height of her vertebral fracture at L1.  The examiner noted that she had soreness in her coccyx after prolonged sitting.  At the physical therapy ROM study on 25 September 2006, 4 months prior to separation, the examiner noted pain with ROM testing.  Forward flexion was 45 degrees (normal 90).  There was no change after repetitive motion in any of the planes of motion and her total combined ROM was 165 degrees (normal 240).  There were no other examination findings.  There was no VA examination in evidence.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% coded 5235 (vertebral fracture or dislocation), citing painful limitation of motion and tenderness.  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 physical therapy examination.  Although there is evidence in her medical file that indicates that she was placed on convalescent leave for 3 months, there was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula 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 20% for the back condition, coded 5235.  

BOARD FINDINGS:  In the matter of the back condition, the Board unanimously recommends a disability rating of 20%, coded 5235 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	5235	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150529, 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

03 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002051 (PD201500337)

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