RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	               CASE:  PD-2015-01073
BRANCH OF SERVICE:  Army	 Date of separation: 20050101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-5, Military Police, medically separated for “chronic low back pain,” with a combined disability rating of 0%.  

CI CONTENTION: “After initial findings these were corrected at the V.A.  No rating on GERD and Headaches.”  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	VARD 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	0%	DDD of Lumbosacral Spine	5242	10%	20050325	
Migraine Headache	Not Unfitting	Migraine Headaches	8100	10%	20050325	
Right Knee Pain	Not Unfitting	Right Knee Patellofemoral Syndrome	5260-5019	10%	20050325	
RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began between January and March 2003 month.  Treatment notes documented reports of lower back pain with intermittent radiation down the left lower extremity.  Magnetic resonance imaging (MRI) studies performed in August 2003 showed lumbar (L3-4) degenerative disc disease, with small disk bulge at L4-5, but no canal stenosis or neural foraminal narrowing at any level.  An evaluation by orthopedics concluded with a diagnosis of mechanical low back pain.  The CI underwent 2 months of physical therapy without pain resolution.  There was no surgical indication.  Despite treatment, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for MEB.  Treatment records evidence two acute care visits for lower back pain. The CI was issued 24 hours quarters at the July 2003 visit.  At the MEB examination (recorded on DD Forms 2807-1 and DD 2808) dated in January 2004, 12 months prior to separation, the CI reported “lower restrictive movement and back pain” and indicated numbness and tingling related to his back pain.  The physical examination showed positive straight leg raise testing bilaterally for radiculopathy.  The remainder of the examination was within normal limits.  During the physical therapy clinic appointment on 17 March 2004 the examiner recorded the lumbar range of motion (ROM) as forward flexion of one measurement of 60, and two measurements of-65 degrees (90 normal) with a combined ROM of 120 degrees (240 normal).  The MEB NARSUM examination on 10 June 2004 (7 months prior to separation) noted complaints of sharp and tight back pain which ranged from 8/10 to 10/10.  The physical examination showed normal motor, sensory, and coordination functions.  

At the VA Compensation and Pension (C&P) examination on 25 March 2005, performed 3 months after separation, the CI reported back pain which flares every 2 or 3 days.  He also reported he was no longer able to mow his yard without back pain which radiated as a sharp electric pain down to his left knee.  The physical examination showed a positive straight leg raise bilaterally for radiculopathy.  The ROM was recorded as forward flexion of 80 degrees (90 normal) and a combined ROM of 165 degrees (240 normal).  There was no weakness, fatigue or lack of endurance after 5 repetitions; however, there was escalating pain.  The CI had a normal gait.  X-ray results indicated transitional type of vertebral body in the lower lumbosacral spine and minimal narrowing of the disc space at L3-L4.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the chronic back pain condition 0% coded 5299-5237 (lumbosacral strain), citing Army Regulation 625-40, paragraph B-15 (0 percent rating).  The VA rated the back condition 10% coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 3 months after separation, citing painful, limited motion.  The Board agreed that a 10% rating, but no higher, was justified for thoracolumbar forward flexion greater than 60 degrees, but not greater than 85 degrees and a combined ROM greater than 120 degrees, but not greater than 235 degrees..  The Board noted reports of radiating lower extremity pain; however, 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 such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  The Board therefore concluded that additional disability rating for a radiculopathy was not justified in this case. There was no documentation of incapacitating episodes which 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 recommends a disability rating of 10% for the chronic low back pain condition.  

Contended PEB Conditions:  Migraine headache and right knee pain.  The migraine headache condition was not profiled and neither the migraine headache nor the right knee pain conditions were implicated in the commander’s statement; neither was judged to fail retention standards.  Both conditions were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended migraine headache or right knee pain conditions and so no additional disability ratings are recommended

BOARD FINDINGS:  In the matter of the chronic low back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the contended migraine headache and right knee conditions, 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.  

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

CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain	5242	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150608, 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 XXXXXXXXXXXXXXXXXX AR20160014752 (PD201501073)

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