RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00899
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070420

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Signal Support Systems Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20070405	VARD - 20071026	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Facet Arthropathy, LS-SI and Disc Bulge	5099-5010	10%	STR	
Right Shoulder Pain	Not Unfitting	Right Shoulder Pain	5299-5201	NSC		
Left Knee Pain		Chondromalacia Patella, Left Knee	5299-5257	0%		
Atypical Depressive Disorder		Depressive Disorder	9434	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in December 2004 after falling from a ladder.  Diagnostic imaging (X-ray) studies on 26 September 2006 showed normal thoracic spine and normal cervical spine.  Diagnostic studies (X-ray) 30 October 2006 showed no fracture or dislocation.  The examiner noted a strong suspicion of possible underlying L5-S1 disc degeneration.  Diagnostic imaging (MRI) studies 30 November 2006 revealed minimal bulging intervertebral disks at L4/5 without narrowing of the neuroforamina (space through which the spinal nerve root passes; 8 January 2007 showed degenerative disc at L3-4, L4-5, and L5-S1 with a bulging intervertebral disc at L4-5; 25 January 2007 revealed mild degenerative disc disease at L4-5 and L5-S1.  He received lower facet injections 1 February 2007.  There was no surgical indication.    

The 15 March 2007 MEB NARSUM examination, 2 months prior to separation, noted complaint of daily low back pain rated 5/10.  The pain was aggravated by activity and prevented him from lifting or wearing body armor.  He had no weakness in his lower extremities and no neurological complaints.  Physical examination showed bilateral paraspinal muscle spasms with thoracolumbar flexion to 80 degrees (normal 90) , extension to 0 degrees (normal 30), bilateral side bending to 30 degrees (normal) and bilateral lateral rotation to 30 degrees (normal); combined range of motion of 200 degrees (normal 240).  Thoracolumbar ROM was limited by pain.  

At the 17 June 2008 VA Compensation and Pension (C&P) evaluation, 14 months after separation, the CI reported constant lower back pain rated at 4-5/10 which radiated down his right lateral and posterior leg.  Physical examination showed no tenderness or muscle spasm.  There was normal strength and reflexes.  His ROM was flexion of 90 degrees and a combined ROM of 240 degrees (240 normal).  The examiner was silent regarding gait and spinal contour.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10%, coded 5237 (lumbar spine strain), citing muscle spasm without spinal deformity or gait alteration and flexion of 80 degrees with pain limited motion.  The VA also rated the chronic low back pain condition 10%, coded 5099-5010 (arthritis, due to trauma, substantiated by X-ray findings) based on the STR because the CI failed to report to the scheduled VA C&P examination, citing pain limitation of motion.  The panel 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/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB and Physical Therapy (PT) examinations proximate to separation.  Although there was muscle spasm, it was not 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 panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.

Contended PEB Conditions: Right Shoulder Pain, Left Knee Pain, and Atypical Depressive Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended right shoulder pain, left knee pain, and atypical depressive disorder conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150606, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20170007151, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

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.

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary of the Army

Enclosure