RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00556
BRANCH OF SERVICE:  Army	                        SEPARATION DATE:  20070601

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Wheeled Vehicle Mechanic, medically separated for “chronic low back pain,” with a disability rating of 10%.

CI CONTENTION:  The applicant makes no specific contention in his application.  His 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:  

IPEB - Dated 20070418	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Lumbosacral Spine Trauma with Residuals L5 Spinous Process Irregularity	5237	0%	20070816	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 8 	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20070828 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  The narrative summary (NARSUM) noted the CI initially reported thoracolumbar (TL) back pain (BP) following an injury during basic training when a soldier fell forward hitting the CI’s back with his weapon.  Notes in the record also indicated that X-rays were negative and the CI was treated conservatively with medications and profiles.  The CI was deployed and continued to be treated for BP.  He reported additional exacerbations of BP while running and while lifting a heavy object.  Following redeployment he participated in PT without resolution of the pain.  Lumbar magnetic resonance imaging 19 December 2006 showed mild degenerative disc disease, without significant spinal stenosis or nerve impingement.  The CI was evaluated by physical medicine (PM) for consideration of injection treatments 12 February 2007.  The PM examination noted normal spinal contours.  There was tenderness to palpation (TTP) of the TL muscles bilaterally, but no TTP of the spine or with pressure on the spinal facet joints.  Lumbar range of motion (ROM) was full, without “significant pain.”  Lower extremity strength, sensation, and reflexes were normal and straight leg raise (SLR) testing was negative.  The PM specialist indicated there was no evidence that the TL pain was disc related and was likely myofascial pain and did not warrant injections.  Physical therapy indicated maximal medical improvement from therapy had been attained and an MEB was initiated.

At the MEB examination, the CI reported constant BP, aggravated by activity, with rare radiation to the back of the right leg.  The MEB physical examination cited the examination documented on the DD Form 2808, Report of Medical History, which showed TTP of right lower TL muscles and “mild pain” during TL ROM.  The findings of the PM examination noted above were also cited.  All TL ROM measurements performed by the PM specialist were repeated three times, all ROM was normal, “mild pain” with ROM was noted, and there was no additional loss of ROM with repetition.

At the VA Compensation and Pension (C&P) general examination on 16 August 2007, 3 months after separation, the CI reported constant BP, aggravated by lifting, but noted walking and sitting were unlimited and he could stand “greater than 9 hrs.”  The examination noted a normal gait.  The VA C&P spine examination performed the same day, noted a normal gait and no tenderness, muscle spasm or guarding, abnormal spinal contours, or painful motion.  All lumbar ROM was normal, with no painful motion and no additional loss of ROM with repetition.  Bilateral lower extremity strength, sensation, and reflexes were normal and SLR testing was negative.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the thoracolumbar back condition 10%, coded 5299-5237 (analogous to lumbosacral strain).  The VA rated the TL back condition 0%, coded 5237.  The Board agreed the evidence in record supports a 10% rating according to the VASRD General Rating Formula for the Spine in effect on the date of separation for thoracolumbar “localized tenderness not resulting in an abnormal gait or an abnormal spinal contour” at the MEB examination and did not support the next higher rating of 20% based on limited ROM or “muscle spasm or guarding severe enough to result in an abnormal gait or an abnormal spinal contour.”  The Board reviewed to see if a higher evaluation than 10% was achieved coding with 5243 (Intervertebral disc syndrome) and rating based on incapacitating episodes, defined by the VASRD as bed rest prescribed by a physician and treatment by a physician.  However, there were no incapacitating episodes as defined documented in the record.  After due deliberation in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

The Board also considered if there was evidence in the record to support recommending peripheral nerve impairment due to the back condition as separately unfitting and eligible for additional disability rating.  The CI had reported rare radiation of pain to the RLE, but strength, sensation, and reflexes were normal throughout the record.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a and since no evidence of a motor or fixed sensory deficit associated with functional impairment exists in this case, the Board cannot support a recommendation for additional rating on this basis.

BOARD FINDINGS: In the matter of the 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 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160014881 , XXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure