RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00557
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061215

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

CI CONTENTION:  The CI made no specific contention.  The CI’s complete submission is 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 - 20061107	VARD - 20070817	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	0%	Degenerative Disc Disease, Lumbar Spine	5242	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition insidiously began in 2005 and eventually was worsened by prolonged sitting, standing, walking, bending, reaching, and lifting.  The CI endorsed intermittent radicular pain in both legs down to the knees.  X-rays of the lumbar spine revealed mild multi-level degenerative disc disease (DDD).  Despite non-surgical 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 an MEB.  The MEB forwarded “chronic low back pain,” for PEB adjudication.  

At the MEB NARSUM examination dated 24 September 2006, 3 months prior to separation, the CI reported daily lower back pain with occasional radicular pain going down both lower legs.  His physical examination (PE) revealed full range of motion (ROM) of his lumbar spine.  There was no evidence of tenderness or muscle spasms about the lumbosacral spine.  The CI was able to squat, heel to toe walk, and had normal sensation and strength of his lower extremities.  Bilateral straight leg raise testing was negative for any degree of radicular pain.  His neurological examination was normal.  The CI failed to report for his scheduled VA Compensation and Pension (C&P) general medical or spine examination in June 2007, but a VARD dated 17 August 2007 noted a 0% rating.  Therefore, the Board’s final rating recommendation will be based upon the STR and MEB NARSUM documentation.  
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 0%, coded 5237 (lumbosacral strain) and cited no tenderness or mechanical loss of motion.  The VA rated the same condition 0% coded 5242 (degenerative arthritis), and cited full ROM of the thoracolumbar spine based upon the CI’s STR.  There was no limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine and the MEB NARSUM examination did not note the presence of painful motion, muscle spasm, guarding or localized tenderness.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height, nor was there evidence of additional functional loss that would impact occupational activities.  There were no incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for intervertebral disc syndrome (IVDS), nor was there evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  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’s adjudication for the chronic low back pain condition.  

BOARD FINDINGS:  In the matter of the chronic 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 modification or 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018755 (PD201500557)

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