RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00400
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Fire Support Specialist, medically separated for “chronic back pain,” with a disability rating of 10%.  

CI CONTENTION:  The applicant makes no specific contention in the application.  The applicant’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 - 20050815	VARD - 20071101	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5237	10%	Lower Back Spasms	5237	20%	20070613	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Lumbosacral Strain Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lumbosacral strain condition began in July 2004 after he jumped into a foxhole with all of his heavy gear and wrenched his back.  Radiographic studies showed normal disc spaces, bone contour, and alignment with no evidence of fracture, dislocation, or other bone abnormality.  The lumbar curve was normal and joints were within normal limits.  The lumbar spine was normal.  There was no surgical indication.  Despite treatment, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for MEB.
  
At the time of the MEB NARSUM appointment on 26 April 2005, 5 months after separation, the CI reported 7/10 throbbing low back pain which increased to 7/10 stabbing pain with activity.  On examination he had full thoracolumbar ROM.  He had tenderness to palpation in the mid-back (lower thoracic/upper lumbar region).  His lower extremity examination was normal with negative straight leg raise (no pain during the leg raise indicative of no radiculopathy).  His sensory and strength examinations were normal.  At the VA Compensation and Pension (C&P) examination on 13 June 2007, 3 years and 1 month after separation, the CI reported chronic lower back spasms that have progressively worsened and radiated up into his shoulders.  Physical examination showed full range of motion of the lumbar spine.  There was no tenderness, spinal ankylosis, or evidence of fracture.  He had a positive straight leg raise bilaterally.  Painful motion began and ended at the following degrees:  Flexion 45 to 90; Extension 20 to 30; Left lateral flexion 15 to 30; Left rotation 20 to 30.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (lumbosacral or cervical strain), citing without neurologic abnormality or limitation of thoracolumbar range of motion, with localized tenderness.  The VA assigned a 20% rating using 5237 code (lumbosacral or cervical strain) based on the VA C&P examination 3 years and 1 month after separation, citing painful motion. 
Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of tenderness and painful motion.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  The Board considered whether additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had occasional symptoms of radiating pain documented in the treatment records, but examinations indicated normal strength and reflexes (there was no abnormal gait reported) and the sensory changes did not affect his job.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation specific activities.  There is no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concludes that additional disability rating was not justified on this basis.  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 chronic back pain condition.

BOARD FINDINGS: In the matter of the chronic back pain 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 20150529, w/atchs
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, AR20160014389 (PD201500400)

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