RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00585
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060826

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

CI CONTENTION:  The CI was diagnosed with other conditions by the VA.  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 - 20060814	VARD - 20070212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5237	10%	Lumbosacral Degenerative Disc Disease	5242	NSC	20061111	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Low Back Pain (LBP).  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initially injured his low back after lifting approximately 100 pounds 3 months prior to entering the Service (1 September 2005). The CI reported the back pain had “largely resolved” by the time he entered the Army and the condition was not acknowledged at the MEPs initial entry examination.  Absent direct trauma, the CI began experiencing increasing back pain on day seven of basic training.  Imaging studies (X-rays) performed on 23 June 2004 (prior to entering service) revealed moderate disk bulge about the lumbosacral spine.  Repeat imaging performed in March 2006 revealed degenerative disc disease (DDD) of the same spinal area without spinal stenosis or nerve root compression.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of basic training and the CI was referred for an MEB.  The MEB forwarded “low back pain without radicular symptoms” for PEB adjudication.

A physical therapy (PT) clinical evaluation on 13 June 2006 (3 weeks prior to the MEB NARSUM) noted the thoracolumbar range of motion (ROM) was painful and resulted in 50 degrees of flexion (normal = 90) and  a combined ROM of 190 degrees (normal = 240).  At the MEB NARSUM examination on 6 July 2006, 2 months prior to separation, the CI’s chief complaint was “low back pain”.  His physical examination (PE) revealed a “limp” gait.  There was tenderness and spasm present about the lower lumbar spine, bilaterally.  Thoracolumbar range of motion (ROM) was painful and described as “approximately 15 degree of flexion”, extension as “essentially 0 degrees”, and lateral bending as “perhaps 10 degrees”.  Distal strength and neurosensory components were normal.  At the 11 November 2006 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported constant back pain at levels of 6-8/10.  The PE revealed a left-sided favored limp.  Thoracolumbar ROM remained painful, but normal in all dimensions except forward flexion which measured at 40 degrees (normal = 90).  There was no guarding present nor any evidence of muscular spasms.  Distal strength and neurosensory components were normal.         

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 10%, coded 5299-5237 (lumbosacral strain), citing tenderness, spasm, and ROM limited by pain.  Additionally, the PEB determined the existed prior to service (EPTS) factor to be undetermined.  Based on the C&P examination 3 months after separation, the VA determined the back condition as EPTS and found no evidence that the back condition permanently worsened as a result of service and therefore did not service-connect the back condition.  

Board members first deliberated and agreed that the MEB NARSUM examination, having incomplete and vague ROM documentation, held little probative value in this case and therefore, the PT evaluation and the VA examination (3 months before and after separation) held greatest probative value in determining a disability rating.  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on both of the above mentioned clinical evaluations.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the back condition, coded 5237.  

BOARD FINDINGS:  In the matter of the low back condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, 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, AR20170000267 (PD201500585)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA