RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01071
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051015

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

CI CONTENTION:  The CI’s back condition has worsened and added to his anxiety level.  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 upon a 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 - 20050721	VARD - 20060313	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lower Back and Sacral Pain	5299-5236	0%	Thoracolumbar Disc Herniation with Mild Right Sacroiliitis	5243	0%	20060207	
Adjustment Disorder with Depressed Mood	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Lower Back and Sacral Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s “chronic lower back and sacral pain” condition began in September 2003 of an unknown etiology.  Radiologic imaging revealed evidence of sacroiliac joint inflammation as well as “minimal degenerative changes” about the lumbar spine.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “lower back pain with L5-S1 mild disk herniation” and “lower back pain with right sacroiliitis” for PEB adjudication.  At the time of a physical medicine appointment on 11 January 2005, the CI reported sharp low back pain radiating to both buttocks; aggravated by lifting, running and sneezing, and alleviated by rest.  On examination, the CI was in no apparent distress and there was no numbness, weakness, or lower extremity radicular pain.  Thoracolumbar range of motion (ROM) was within normal limits.  At the MEB NARSUM examination on 27 May 2005, 5 months prior to separation, the CI’s chief complaint was “low back pain.”  His physical examination (PE) revealed normal or above normal ROM in all directions except for a 10 degree deficit in extension of 20 degrees (normal 30).  Bilateral lateral spinal flexion was over doubled normal values.  Only extension was limited by pain whereas all other directional movements were limited by mechanical body habitus.  Spinal tenderness was not present and there was no comment with regards to spasm or guarding.  His gait was normal.  At the 2 February 2006 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported intermittent low back pain at 4-5/10 for which he took no medications, as well as intermittent numbness and tingling in both thighs.  The PE revealed a normal gait and ability to heel and toe walk.  Strength and neuro-sensory parameters to the lower extremities were normal/intact.  Thoracolumbar ROM was normal and above normal in extension and rotation, bilaterally. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic lower back and sacral pain condition at 0%, analogously coded 5299-5236 (sacroiliac injury and weakness), citing full motion without tenderness.  The VA also rated the low back condition at 0% under the primary code of 5243 (intervertebral disk syndrome) based on the VA C&P examination 4 months after separation, citing full and painless ROM of the back.

The Board majority agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB examination.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the “chronic lower back and sacral pain” condition, coded 5299-5236.  

Contended PEB Conditions:  Adjustment Disorder with Depressed Mood.  The Board’s main charge is to assess the fairness of the PEB’s determination that the above listed 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’s fitness determination for the adjustment disorder with depressed mood condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic lower back and sacral pain condition, the Board majority recommends a disability rating of 10%, coded 5299-5236 IAW VASRD §4.71a.  The single voter for dissent recommended no change from the PEB’s adjudication and did not elect to submit a minority opinion.  In the matter of the contended adjustment disorder with depressed mood condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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	
Chronic Lower Back and Sacral Pain	5299-5236 	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

AR20170011800, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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 also been provided to the Department of Veterans Affairs

Sincerely,	
Enclosure