RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2015-00847
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090818

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Combat Medic Trainee, medically separated for “lumbosacral strain” with a disability rating of 10%.  

CI CONTENTION:  The CI requests the Board consider 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 determination is confined to 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 - 20090805	VARD – No claim submitted	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5299-5237	10%	No VA Claim	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY: 
 
Lumbosacral Strain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lower back condition began in October 2008 while in basic training.  The CI denied any specific injury or trauma.  There was no surgical indication and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “non-radicular lower back pain” for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated May 2009, 3 months prior to separation, the CI reported “chronic lower back pain with numbness and tingling in legs.”  The Physical examination recorded lower back pain and “numbness and tingling after walking 1/4 mile.”  

The MEB NARSUM examination on 22 May 2009, 3 months prior to separation, noted complaints of lower back pain for the previous 8 months and that the symptoms worsened with doing push-ups, sit-ups, impact activities or any type of heavy lifting.  The physical examination showed active range of motion of 80 degrees forward flexion (90 normal), 15 degrees of extension (30 normal), 15 degrees of left and right side bend (30 normal), and 20 degrees of left and right rotation (30 normal) with “mild increased pain at the upper limits of all ranges.”  Motor strength was recorded as 5/5 with intact sensory to light touch “distally bilaterally” and “diffuse tenderness to palpation about the paraspinal muscles from approximately L1-S1.”  A VA Compensation and Pension (C&P) evaluation was not performed.  
	
The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the lumbosacral strain condition 10% coded 5237 (lumbar spine strain), based on limitation of motion.  There was no indication that the CI submitted a claim to the VA.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees) as reported on the NARSUM examination proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, 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 lumbosacral strain condition.  

BOARD FINDINGS:  In the matter of the lumbosacral strain 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, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXX, AR20160015158 (PD201500847)

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