RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01068
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080907

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

CI CONTENTION:  The CI requests the Board consider 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 - 20080602	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Upper Back Pain	5237	10%	No VA examination in evidence	
Elevated Blood Pressure	Not Unfitting 		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Upper Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic upper back pain condition began in July 2007 after doing sit-ups during a physical fitness test.  A thoracic spine (T-spine) radiograph on 29 October 2007 revealed mild dextro-convex curvature centered at the T5/6 level with no other abnormalities identified.  A scoliosis survey completed on 6 November 2007 showed 5 degrees apex right curvature of the mid-thoracic spine; described as of questionable clinical significance.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic upper back pain” for PEB adjudication.  

At the time of the Primary Care clinic appointment on 3 March 2008, the CI reported pain (4/10) located in the right and left paraspinal muscles between the shoulder blades, exacerbated by any movement of the back and shoulders.  He also reported not seeing improvement with physical therapy treatment.  On examination, the CI had a normal visual appearance of the back, without any scoliosis or deformity.  There was full range of motion (ROM) on all measurements with no pain.  There was tenderness to palpation in the paraspinal muscles on the right and left.  Deep tendon reflexes were 2/4 bilaterally and the CI possessed normal (5/5) strength on all extremities.  There was no scapular winging; he was able to duck walk and perform pushups without difficulty.  There was no pain with axial loading.  There was negative testing for radicular signs and no non-physiologic findings.  A spine MRI performed on 21 March 2008 revealed a normal examination.  

The MEB NARSUM examination on 13 May 2008, 4 months prior to separation, noted complaints of baseline pain of 3-4/10, described as a tightness “like a knot” between his shoulder blades bilaterally.  It was relieved temporarily by pushing back on the shoulders and cracking the back.  There was also some numbness between the shoulder blades.  Physical exam showed neck and back with normal appearance and full ROM with mild pain only at extremes of motion.  There was a very mild tenderness to the left paraspinal area at the T5-T8 level, but no spasm or guarding.  Deep tendon reflexes were symmetric.  Strength was normal (5/5) in both upper extremities and there was no sensory deficit.  There was no apparent scoliosis, and no non-physiologic findings.  

There was no VA compensation and pension exam in evidence.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic upper back pain condition 10%, coded 5237 (lumbar spine strain), citing tenderness.  There was no VA rating in evidence.  lthough there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of tenderness and/or painful motion.  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 documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  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 upper back pain condition.  

Contended PEB Conditions:  Elevated Blood Pressure.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic upper back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended elevated blood pressure condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20150601, with attachments
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, AR20170001107 (PD201501068)

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