RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01024
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Motor Transport Operator, medically separated for “low back pain,” with a disability rating of 0%.  

CI CONTENTION:  “Please review 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 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 – 20050202	VARD – 20050511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	0%	Degenerative Disc Disease, Lumbar Spine	5243	0%	20050223	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s condition began in February 2002, while deployed after he was involved in a tactical vehicle accident.  In April 2001 he woke up with back pain.  The work-up was negative for fractures, but his back pain was exacerbated.  Magnetic resonance imaging studies 1 September 2004 showed mild to moderate spinal stenosis at L4-L5 and L5-S1 levels.  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 an MEB.  The MEB forwarded “chronic low back pain” for PEB adjudication.  

At the October 2004 MEB examination (recorded on DD Forms 2807 and 2808), 7 months prior to separation, the CI reported low back pain with numbness in his legs.  Physical examination showed a normal gait and no tenderness.  Reflexes, muscle strength and sensation were all normal.  Examination for radicular signs was negative.  

The MEB NARSUM examination on 20 October 2004, 7 months prior to separation, noted complaints of worsening back pain and no significant improvement with treatment.  Physical examination showed a normal gait and no tenderness.  Reflexes, muscle strength, and sensation were all normal.  Examination for radicular signs were negative.  The examiner specified that the physical therapy (PT) evaluation had slight limitation of motion due to pain.  Thoracolumbar range of motion (ROM) measurements performed by PT on 3 November 2004 showed flexion of 90 degrees (normal 90) and combined ROM of 220 degrees (normal 240) after repetition.  

At the 23 February 2005 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, the CI reported back pain and limited relief with treatment, but was taking no medication or other treatment.  The CI reported his back condition did not interfere with his ordinary lifting or carrying.  Physical examination showed a normal posture and gait.  Motor, reflexes and sensation were normal.  There were no muscle spasms.  Straight leg raise testing was normal.  ROM was flexion of 90 degrees and a combined ROM of 240 degrees without pain.  There was no pain, weakness, lack of endurance, fatigue or incoordination.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 0%, coded 5237 (lumbar spine strain), citing flexion of 90 degrees, extension of 30 degrees, and no tenderness.  The VA rated the back condition 0%, coded 5243 (intervertebral disc syndrome [IVDS]), based on the VA C&P examination 3 months before separation, citing full non-painful ROM.  

The Board agreed that a 10% rating, but no higher, was justified for a combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM PT examination.  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.  There was no evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  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 recommends a disability rating of 10% for the back condition, coded 5237.  

BOARD FINDINGS:  In the matter of the back condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150609, 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 XXXXXXXXXXXXXXXXXXXXX, AR20170001066 (PD201501024)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA