RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01064
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080704

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 “chronic low back pain…” with a disability rating of 20%.

CI CONTENTION:  The CI contends for his unfitting low back pain and a condition not identified by either the MEB or PEB.  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 - 20080509	VARD - 20100216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5237	20%	Back/Tailbone Condition	5299-5237	NSC	20090504	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his back in May 2006 when ejected from his vehicle while deployed to Iraq.  He was treated in theater and the pain persisted after re-deployment.  Diagnostic imaging (MRI) was normal.  There was no documentation in STR clinical entries of radicular symptoms.  Multiple neurological examinations were normal, with none to the contrary.  There were multiple entries documenting grossly normal range of motion (ROM), although there were some indicating limitation of extension.  There were no entries indicating more significant ROM limitation.  There was STR documentation of normal gait, with none to the contrary; although, there was some non-specific evidence for abnormal spinal contour (none correlated with spasm or guarding).  There was no STR documentation of incapacitating episodes.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for an MEB.  The MEB forwarded “chronic low back pain” for PEB adjudication.    

The NARSUM examination on 19 June 2008 (3 weeks before separation) documented chronic pain (unquantified) without radiation or neurological symptoms.  Functional limitations were not elaborated, although the commander’s performance statement referenced pain with standing longer than 10 minutes, with lifting more than 5 pounds, and with all general soldiering requirements.  The physical examination recorded a normal spinal contour, “mild” tenderness, no spasm, and normal neurological findings (5/5 strength, intact sensation, symmetric reflexes).  Goniometric ROM measurements by physical therapy (PT) were added to the NARSUM, documenting flexion to 60 degrees (normal 90) with a combined ROM of 205 degrees (normal 240).  

A VA Compensation and Pension (C&P) examination on 4 May 2009 (10 months after separation) documented back pain, with occasional left hip radiation but no motor or sensory symptoms, rated 2-3/10 with exacerbations to 10/10 by prolonged sitting and lifting.  The physical examination recorded a normal gait, normal neurological findings (5/5 strength), estimated flexion to 90 degrees, and estimated bilateral flexion to 30 degrees (normal).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated 20% under code 5299-5237 (analogous to lumbar strain), citing the PT ROM, with the PT flexion of 60 degrees meeting the VASRD §4.71a 20% criterion of “greater than 30 degrees but not greater than 60 degrees.”  The VA did not service connect the condition, citing the failure of the CI to provide requested service records (although acknowledging the C&P examination).  There was no ROM evidence supporting a rating higher than 20%, no evidence of additionally ratable peripheral nerve impairment, and no documentation of incapacitating episodes (or diagnosis of intervertebral disc syndrome) that would provide for a higher rating under that formula.  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 of the lumbar condition.  

BOARD FINDINGS:  In the matter of the lumbar 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 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

08 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001103 (PD201501064)

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