RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00375
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Unit Supply Specialist, medically separated for “chronic low back pain” with a disability rating of 0%.  

CI CONTENTION:  The CI contends for his unfitting back condition and a number of conditions not identified by either the MEB or PEB.  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 - 20050523	VARD - 20060208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5239	0%	Chronic Low Back Pain with Strain, Bilateral Pars Defect L5-S1, and Grade I Spondylolisthesis	5239	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 2001 after heavy lifting. Radiographic studies in February 2004 showed mild degenerative changes at L4-5 and L5-S1 with a mild grade I spondylolisthesis at L5-S1 and neuro-foraminal stenosis, but no central stenosis.  There was no surgical indication.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “chronic low back pain with grade I spondylolisthesis” for PEB adjudication.  

The commander’s statement on 25 April 2005, 2 months prior to separation, stated that “(the CI’s) medical condition does not prohibit him from performing his duties or other duties required by his MOS;” “he can complete the APFT with an alternate event for the run;” and “he is able to work through and around his medical condition to complete all tasks without causing further damage to his body.”  

The MEB NARSUM examination on 26 April 2005, 2 months prior to separation, noted complaints of back pain.  Physical examination showed a normal gait with a good range of motion (ROM), but pain during flexion.  Provocative testing for radiculopathy was negative.  Gait, sensory, motor, and reflex examinations were normal.  Physical therapy ROM measurements taken on 25 April 2005 showed normal flexion of 90 degrees and a combined ROM of 235 degrees (normal 240).  The CI failed to report for a January 2006 VA Compensation and Pension (C&P) evaluation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5239 (spondylolisthesis) citing no tenderness to palpation and normal ROM.  The VA also rated the back condition 0% coded 5239 based on STRs, and failure to report for a VA examination.  The physical therapy ROMs were not normal, but lacked 5 degrees of extension and therefore 5 degrees of combined ROM as computed IAW VASRD general spine formula, note 2 (the VASRD normal ROM for each component of spinal motion are the maximum that can be used for calculation of the combined ROM).  The Board agreed that a 10% rating, but no higher, was justified for painful motion on the NARSUM examination or limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) as reported on the physical therapy examination.  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 back condition, coded 5239.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5239 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	5239	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160014388 (PD201500375)

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