RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00423
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020801

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

CI CONTENTION:  The CI contends for his back pain condition and that the rating should be increased because the condition has worsened.  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 - 20020606	VARD - 20020812	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical Low Back Pain…	5299-5295	10%	Mechanical Low Back Pain	5299-5295	10%	20020415	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Mechanical Low Back Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in January 1998 after a road march.  The CI claimed the weight of the rucksack and distance of the march caused pain in the lower back.  An X-ray series showed mild right convex scoliosis of the mid thoracic spine.  On examination the CI had a normal gait and posture with a full range of motion (ROM) with pain at forward flexion and end rages of side bending.  A lumbosacral spine X-ray series was normal.  The CI underwent physical therapy without relief, while findings of a MOS/Medical Retention Board (MMRB) in June 2000 determined that the CI be retained in his permanent MOS.  However, the medical condition precluded satisfactory performance in a worldwide environment.  The command, however, elected to process the CI for failure to meet body fat standards.  In another MMRB in October 2001 the CI was recommended to be referred to the MEB.  The MEB forwarded “chronic low back pain” for PEB adjudication.

A lumbar spine X-ray series in April 2002 was unremarkable.  Magnetic resonance imaging (MRI) in September 2002 revealed evidence for a central and left paracentral herniated disc the L5-S1 level along with borderline spinal stenosis at the L3-L4 and L4-L5 levels.  

At the MEB examination on 19 March 2002, 6 months prior to separation, the CI reported chronic lower back pain in the mid to lower back and numbness and tingling in both legs from the waist down during activities.  Physical examination revealed tenderness to palpation of the lumbar spine.  The MEB NARSUM examiner on 09 April 2002, 5 months prior to separation, noted the CI’s back had mild tenderness to palpation of the lumbar spine and pain on rotation as well as pain with movement of the lower extremities in their extreme.  He had no ROM limitations associated with his back.  His extremities demonstrated a free ROM without difficulty.  Reflexes were 1+ throughout and he was able to heel and toe walk.  The CI continued to have daily low back pain, but not significant enough to require him to seek medical attention since he responded to nonsteroidal anti-inflammatory drugs (NSAIDs).  He described periods of spasmodic elevations of pain as 8/10 (10 being the worst pain) and a global sensation of lower extremity tingling only when he ran, but no symptoms at rest or when walking or at rest. 

At the 15 April 2002 VA Compensation and Pension (C&P) evaluation, performed 5 months before separation, the CI reported his pain was aggravated by lifting greater than 50 pounds and continued sensation of global tingling in his legs from his waist to his feet whenever he ran.  On examination he had tenderness to palpation on the lumbar spine and pain with rotation.  There was also low back pain with lower extremity ROM bilaterally.  X-rays of the lumbar spine were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5299-5295 (lumbosacral strain), citing chronic mechanical low back pain, without neurologic abnormality or documented chronic paravertebral muscle spasms on repeated examination, with characteristic pain on motion.  The VA also rated the low back condition 10% coded 5299-5295 (lumbosacral strain), based on the VA C&P examination 11 days after separation, citing pain with rotation.  Board members considered whether a 20% rating using code 5295 was warranted; however, there was no muscle spasm on extreme forward bending or loss of lateral spine motion in standing position.  Furthermore, use of code 5292 (spine, limitation of motion of, lumbar) requires moderate limitation of motion; however, the CI had a full ROM.  There was no documentation of intervertebral disc syndrome (IVDS) with “symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to site of diseased disc, little intermittent relief,” which would provide for a higher rating under that formula (for IVDS).  The Board also considered whether an additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had a herniated disc, and there were symptoms of radiating pain documented in the treatment records; however, examinations indicated normal strength, reflexes and gait, and the sensory changes did not affect his job.  The critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  Thus, the Board concluded that an 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 lower back pain condition.  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 mechanical low back pain condition.  

BOARD FINDINGS:  In the matter of the chronic mechanical 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 20150601, 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, AR20160019843 (PD201500423)

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