RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00832
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for low back pain with a disability rating of 20%.  

CI CONTENTION:  The CI made no specific contention.  The 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 - 20080313	VARD – 20141031	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Arthritis, Degenerative, Thoracolumbar Spine	5242	20%	No VA Examination in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain (LBP) condition began in 2004 while deployed without specific injury or trauma.  Radiographic evaluation (MRI) performed in April 2007 documented a herniated disc at the L5-S1 vertebral levels without significant nerve root compression.  Despite 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 MEB.  The MEB forwarded “lumbar spine disc protrusion, lumbago” for PEB adjudication.  

At an emergency room visit on 23 January 2008 (3 months pre-separation), the physical examination showed midline spinal tenderness, an abnormal gait, and inability to straighten the legs due to pain.  At a follow up visit with family practice 2 days later, the physical examination showed spasm, an abnormal gait, and pain causing decreased range of motion (ROM).  At a family practice visit for the MEB on 28 January 2008, the physical examination showed a forward flexion of 20 degrees (normal 90), normal bilateral flexion and rotation, with a normal gait.  

At the MEB NARSUM examination on 7 February 2008 (2 months pre-separation), the CI reported radiating pain and paresthesias in the right foot.  The physical examination showed tenderness without guarding, a normal gait, forward flexion of 55 degrees, extension of 10 degrees (normal 30) and normal bilateral flexion and rotation.  The CI was unable to squat without lower back pain.  There was no VA Compensation and Pension (C&P) evaluation available for review.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the LBP condition 20%, coded 5242 (degenerative arthritis of the spine), citing tenderness and a ROM limited by pain with 55 degrees of forward flexion.  Most clinical entries did not document evidence of flexion to less than 30 degrees in support of a higher rating.  There was a single entry (28 January 2008) that documented a forward flexion of 20 degrees; however a follow up visit (1 week later; MEB NARSUM) documented flexion to 55 degrees.  The Board agreed that this entry was most consistent with the baseline disability at the time of separation; and therefore recommends that the 20% rating, but no higher, was justified for limitation of flexion greater than 30 degrees but not greater than 60 degrees.  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the previous year to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  There was no 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 adjudication for the LBP condition.  

BOARD FINDINGS:  In the matter of the LBP 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 20150604, 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, AR20170000798 (PD201500832)

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