RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00938
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040526

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

CI CONTENTION:  The applicant complains that his back pain and range of motion is getting worse.  The applicant’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 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 - 20040329	VARD - 20040903	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Discogenic Disease with Compression Fracture, Thoracic and Lumbar Spine	5235-5243	10	20040513	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Low Back Pain. According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), 2 months prior to separation, the CI’s back condition began prior to April 2003, without a history of trauma, falls, or other injuries.  At the time of the initial presentation the CI reported lower back and left flank pain which worsened with prolonged sitting, standing, running, and sit-ups.  He reported occasional numbness.  The CI denied any change in bowel or bladder habits or radiation to the lower extremities, stating that The NARSUM physical examination findings were no step-offs and good lower extremity strength with additional findings listed in the chart below.  The examiner referenced an orthopedic consultation which noted that the CI was not a surgical candidate.  Radiographic studies showed a mild compression fracture at T12 to L1, with a possible mild post-traumatic disc protrusion or herniation; and mild posterior disc bulges at L4/5 and L5/S1.  

At the VA Compensation and Pension (C&P) examination, performed 2 weeks before separation, the CI reported daily pain which was exacerbated with running, lifting, bending, climbing stairs, and twisting.  The physical examination showed normal posture and gait and 5/5 muscle strength. Additional physical findings are listed in the chart below.  The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	PT ~4 Mo. Pre-Sep
	MEB ~2 Mo. Pre-Sep
	VA C&P ~2 Wks. Pre-Sep
	
Flexion (90 Normal)	80	100 (90)		
Combined (240)	200	212	>120, < 235	
Comment	Normal gait; slightly abnormal posture w/hinge noted at L2; hyperlordosis in stance; tender to palpation	Slight limp in gait; no tenderness in parapsinal region; negative straight leg raise; moderate lordosis and normal stance; sensation intact	Tenderness to palpation; 2+paraspinous muscle spasm; negative straight leg raise	
§4.71a Rating	10%	10%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (lumbosacral strain), citing tenderness without radiculopathy, paraspinous muscle spasms, or loss of range of motion.  The VA also assigned a 10% rating using dual coding 5235-5243 (vertebral fracture-intervertebral disc syndrome) based on the VA C&P examination 2 weeks before separation.  Although the VA exam did not measure thoracolumbar spine ROMs IAW current VASRD guidelines, the CI's disability picture was adjudged as being closest to having combined ROM of the thoracolumbar spine "greater than 120 degrees but not greater than 235 degrees" which supports a 10% rating. Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of painful motion.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairments (weakness) which separately impaired duty performance.  The Board therefore concluded that an additional disability 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 back condition. 

BOARD FINDINGS:  In the matter of the back 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

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, AR20160014797 (PD201500938)

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