RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00493
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Student/Trainee, medically for “low back pain,” with a disability rating of 10%.

CI CONTENTION:  The CI contends her conditions have 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 on 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 - 20030617	VARD - 20031217	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5295	10%	Lumbosacral Strain	5295	0%	20031002	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back pain Condition.  According to Service treatment records (STR) and the medical evaluation board (MEB) narrative summary (NARSUM), the CI experienced insidious onset of back pain during Advanced Individual Training (AIT), approximately 8 months prior to referral for MEB.  A November 2002 lumbar spine X-ray was normal.  At a 15 November 2002 physical therapy (PT) encounter, the CI complained of insidious onset of low back pain (LBP) 5-6 weeks prior.  She denied a history of trauma or change in symptoms since onset.  The physical exam documented a normal gait.  The back exam revealed tenderness over the left L4-L5 area.  Active range of motion (ROM) was full except left trunk side bending was 20 degrees.  Strength and sensation were normal.  The diagnosis listed LBP.  A thoracic and lumbar spine diagnostic imaging (MRI) study in April 2003 was normal.  At an 11 April 2003 neurosurgery evaluation, the CI complained of sharp, 6-7/10 LBP since November 2002.  The pain was below the belt line and radiated to the bilateral lower extremities (R>L).  Thoracolumbar ROM was “full” in all planes of motion.  Gait was normal.  The neurosurgeon recounted the findings of the normal MRI and documented that no neurosurgical intervention was indicated.  The impression listed thoracolumbar myofascial dysfunction.  In the 16 April 2003 physical medicine encounter, the CI complained of back pain beginning in AIT without a specific injury.  Lower back pain progressively worsened and involved the thoracic area.  Pain was 3-6/10, and reached 8/10 after prolonged standing or heavy lifting.  Pain radiated to right posterior thigh several times per week, and lasted a few minutes.  The CI denied limb weakness, numbness, tingling, and bowel or bladder problems.  She denied symptom improvement with PT (stretching, ultrasound, and lumbar stabilization exercises).  The back exam revealed bilateral lumbar paraspinal trigger points (tender loci which refer pain).  Back ROM was full with pain at end range or flexion, extension, and lateral bending bilaterally.  The straight leg raise (SLR) tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  The assessment listed chronic myofascial LBP with no neurologic deficit noted on exam.  

The 6 June 2003 NARSUM reflected the findings of the 15 April 2003 exam, 4 months before separation.  The CI complained of insidious progression of LBP since November 2002.  Pain occurred 85% of the time and there was no improvement with PT.  The physical exam documented a normal gait.  The back exam revealed bilateral lumbar and thoracic tenderness with no muscle atrophy.  Back ROM was normal with characteristic pain.  Strength, sensation, and DTRs were normal.  The author cited the neurosurgery and physical medicine consultations and recounted the findings of the normal X-rays and MRI.  The diagnosis listed non-radicular LBP.  

In the 2 October 2003 VA Compensation and Pension (C&P) exam, 2 months after separation, the CI complained of intermittent LBP, after prolonged sitting or standing, approximately once a week.  She was able to run without discomfort.  The CI denied radicular symptoms, flare-ups, need for any assistive device, or medication use.  The physical exam documented a normal gait.  The back exam revealed no tenderness, abnormal spinal curvature, or paraspinal muscle spasms.  Thoracolumbar spine ROM was flexion of 90 degrees and combined 240 (normal 240) degrees.  Repetitive ROM did not cause discomfort or decrease the ROM.  Strength, sensation, and DTRs were normal.  The impression listed lumbosacral strain with rare symptoms.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5295 code (lumbosacral strain) citing non-radicular LBP, no neurologic abnormality, no chronic paravertebral muscle spasms, and characteristic pain on motion.  The VA assigned a 0% rating under the 5295 code (lumbosacral strain) based on the VA C&P exam 2 months after separation, citing lumbosacral strain, no specific injury or trauma, episodic non-radicular LBP, normal X-rays and MRI, normal ROM, no discomfort or decreased motion with repetitive ROM, normal motor and sensory exams, and no abnormal curvature, tenderness, or paraspinal muscular spasms.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation.  The Board noted that the 2002 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The Board must correlate the above clinical data with the 2002 rating schedule and applicable diagnostic codes.  There was no vertebral fracture (5285), complete spine ankylosis (5286), dorsal spine ankylosis (5288), lumbar spine ankylosis (5289), limitation of dorsal spine motion (5291), limitation of lumbar spine motion (5292), or sacro-iliac injury/weakness (5294) for consideration under the respective codes.  There was no neuropathy, characteristic pain, muscle spasm, absent DTR, neurological findings appropriate to disc site, or recurring attacks for consideration under intervertebral disc syndrome (5293).  Board members agreed a 10% rating was supported under lumbosacral strain (5295) based on characteristic pain on motion.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 low back pain condition.  

BOARD FINDINGS:  In the matter of the low 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 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, AR20160018725 (PD201500493)

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