RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00889
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aircraft Powertrain Repairer, medically separated for “low back pain” with a disability rating of 10%.

CI CONTENTION:  The CI contends for his unfitting back condition.  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 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 - 20021114	VARD - 20030306	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5295	10%	Mechanical Low Back Pain	5295	10%	20030113	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 1998 during basic training.  In January 2001 the CI reported low back pain (LBP) for over 2 years, without specific trauma.  The pain occasionally radiated to both hips but not beyond and was aggravated by activity.  He denied any bowel or bladder problems.  Orthopedic evaluation in November 2001 noted tenderness of the lumbosacral ligaments bilaterally with muscle spasm present.  A bilateral lower extremity examination was normal and maneuvers to elicit radicular pain were negative.  Back X-rays were normal.  Medications and physical therapy (PT) did not resolve the back pain and there was no surgical indication.  

At the 31 July 2002 MEB Physical Medicine and Rehabilitation (PMR) consult evaluation, 8 months before separation, the CI reported LBP aggravated by activities, with intermittent numbness/tingling of the toes, greater on the left than right, but with no permanent sensory deficit.  The physical examination showed normal spinal contours.  There was tenderness of the spinal column that reproduced most pain.  Straight leg raise testing (SLR) to elicit radicular symptoms and tests for sacroiliac joint (SIJ) pain were negative.  Lower extremity strength, sensation, and reflexes were normal.  Back range of motion (ROM) was mildly decreased with 65 degrees of flexion noted.  There were no inappropriate pain responses to examination maneuvers documented.  Lumbar spine and hip X-rays were noted to be unremarkable.  The 
3 October 2002 MEB NARSUM examination, 4 months before separation, noted the same symptoms as reported on the MEB PMR consult.  The pain was alleviated by rest, position changes, and stretching.  Anti-inflammatory medications and PT were not helpful.  The physical examination reported the same findings as the PMR examination.  At the 13 January 2003 VA Compensation and Pension (C&P) evaluation, one month before separation, the CI reported LBP aggravated by activities and improved with rest.  He reported occasional radiation down the left leg, without neurological symptoms.  Physical examination showed normal posture and gait.  There were no abnormal spinal curvatures.  There was tenderness in the lower lumbar region.  Testing for SIJ pain and SLR were negative.  Spine ROM was measured with a goniometer and a “mild decrease” in ROM was noted with painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic back pain condition 10%, coded 5299-5295 (lumbosacral strain), under the VA rules for rating the spine in effect on the date of separation, citing reported pain with movement.  The VA also rated the back condition 10%, coded 5295 based on the C&P examination one month before separation. The Board is required to make its rating recommendation based upon VA rating rules in effect on the date of separation.  There was evidence of “characteristic pain on motion” for a 10% rating coded as 5295 and there was no evidence of muscle spasm on forward bending and/or loss of lateral motion on standing for the next higher rating.  There was no evidence of lumbar spine ankylosis (5289), moderate limitation of lumbar spine motion (5292), or intervertebral disc syndrome (5293) for consideration of higher ratings under these respective codes.  There was therefore no higher rating than 10% as adjudicated by the PEB available with any applicable code.  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 back pain condition. 

BOARD FINDINGS:  In the matter of the chronic back pain 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 20150608, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,