RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00710
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “chronic low back pain (LBP) with scoliosis,” rated at 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 20080411	VARD - 20150212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP with Scoliosis	5299-5237	10%	Thoracic Scoliosis	5299-5239	Not Service Connected (NSC)	20150204	
Headaches 	Not Unfitting	Migraine/Tension Headaches	8100	30%	20150204	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in November 2006 after her bunk bed collapsed on her.  Multiple radiographic (X-ray) imaging studies performed in 2007 and 2008 revealed mild mid-thoracic scoliosis (curvature of the spine) with mild compensatory lumbar scoliosis.  Her condition did not indicate surgical intervention and despite medication and physical therapy (PT), her back pain remained as to not allow her the performance of unrestricted duty.   She was sent to an MEB.  The MEB forwarded “LBP” for PEB adjudication.  At the MEB NARSUM examination on 31 March 2008 (3 months prior to separation), the CI’s chief complaint was LBP.  She additionally endorsed functional limitations of an inability to run, wear IBA, lift or carry a load, or ride in a tactical vehicle.  Her physical examination (PE) revealed a full range of spinal motion, spinal curvature as described above, and tenderness to the left-sided muscles adjacent to the spine.  

The VA Compensation and Pension (C&P) examination was performed nearly 8 years remote from separation and therefore, outside of this Boards review period.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition at 10%, analogously coded to 5237 (lumbosacral strain).  The VA rated the thoracic scoliosis condition as “not Service connected” and analogously coded to 5239 (spondylolisthesis or segmental instability), based on the remote VA examination, citing that the condition existed prior to service.  All Board members first agreed that the serial X-rays taken in 2007 consistently documented the presence of a mild curvature in the upper spine with a compensatory curve in the lower spine.  There was no clinical examination evidence near the time of the serial X-rays that confirmed the presence of muscle spasms causing any degree of altered spinal contour.  Members agreed that the mild scoliosis, and its compensatory component, was consistent with a developmental curvature commonly seen as an incidental finding on routine X-rays.  Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of spinal tenderness.  There was no muscle spasm or guarding severe enough to result in an abnormal gait, thus the next higher 20% rating was not justified on this basis.  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 chronic LBP with scoliosis condition.  

Contended PEB Condition:  Headaches.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance based evidence from the record that the condition significantly interfered with satisfactory duty performance near separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB’s fitness determination for the contended headache condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic LBP with scoliosis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended headache condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160019450 (PD201500710)

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