RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00705
BRANCH OF SERVICE:  Army 	SEPARATION DATE: 20090724

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Paralegal Specialist, medically separated for “chronic back pain with mild scoliosis of [the] thoracic spine,” with a disability rating of 10%.

CI CONTENTION:  The CI contends that his back condition continues to worsen.”  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 - 20090605	VARD - 20050729	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain with Mild Scoliosis of [the] Thoracic Spine	5237	10%	Musculoskeletal Strain, Thoracic Spine with Questionable History of Closed Vertebral Fracture at T8	5237	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Back Pain with Mild Scoliosis of [the] Thoracic Spine.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in March 2004 with insidious onset after wearing body armor.  The back pain was aggravated by lifting sandbags and continued throughout his deployment (February 2004 - March 2005).  Other than mild thoracic scoliosis and a hemangioma (benign tumor) at spinal level T4, radiographic studies of December 2008 were normal.  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 thoracic back pain” and “scoliosis [of the] thoracic spine” for PEB adjudication.  At the MEB NARSUM examination on 4 May 2009 (3 months prior to separation), the CI endorsed a constant, non-radiating dull 4/10 thoracic spine ache that was aggravated by “lifting, sitting, standing, and sleeping with a pillow.”  The CI denied any peripheral numbness or weakness.  His spinal-focused physical examination was normal excepting pinpoint tenderness over the mid to lower thoracic spine.  The range of motion (ROM) examination of the thoracolumbar spine was conducted 6 months prior to the MEB NARSUM and indicated painful, but minimal loss of motion.  No other spinal ROM was documented.  

The CI did not report for a VA Compensation and Pension (C&P) examination scheduled on 24 March 2005 and therefore, its final 0% VA rating determination was based upon the STR.   

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 10%, coded 5237 (lumbosacral strain), citing forward flexion greater than 60 degrees but not greater than 85 degrees due to functional loss from pain.  The Board agreed that a 10% rating, but no higher, was justified for painful motion IAW VASRD §4.59.   The next higher 20% rating was not justified in the absence of muscle spasms or guarding severe enough to result in an abnormal gait or spinal contour.  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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

BOARD FINDINGS:  In the matter of the 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 20150605, 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, AR20170000057 (PD201500705)

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