RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01098
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Army Reserve E4, Military Police, medically separated for “low back pain,” with a disability rating of 10%.  

CI CONTENTION:  The CI requests the Board consider all conditions.  His 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 - 20080421	No VA Claim	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain…	5299-5237	10%	N/A	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Low Back Pain, Evaluated as a Back Strain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain (LBP) began in July 2003 during basic training after marching with a field pack.  An MRI in January 2004 showed a herniated disc at L4-5 and a disc bulge at L3-4.  The pain continued while the CI was in weekend drill status, during a deployment and in the subsequent years of service.  There was no surgical indication, and conservative treatment (including duty restrictions and medications) did not result in improvement sufficient to allow a return to unrestricted duty.  The CI was then referred to an MEB.  The MEB forwarded “low back pain with mild bulge and HNP L 4-5 with moderate central canal stenosis” for PEB adjudication.  

The MEB NARSUM examination on 26 February 2008, 3 months prior to separation, noted complaints of constant and slight LBP that radiated to the posterior lateral left thigh.  The CI reported no bowel or bladder problems, or difficulty walking.  The physical examination showed normal gait without tenderness to palpation and normal curvature of the spine.  The neurological examination was normal.  The examiner noted occasional lumbar paravertebral spasm with forward, right lateral and backward bending.  The range of motion (ROM) measured with a goniometer recorded forward flexion of 120 degrees (normal 90) and extension of 30 degrees (normal 30).  The ROM exceeded the VA normal values in all planes.  Motion was limited by pain. At the 24 March 2008 MEB examination (recorded on DD Forms 2807 and 2808), 2 months prior to separation, the CI reported “two herniated disks” in his lower back as a result of the aforementioned injury in basic training.  The physical examiner noted LBP and an otherwise unremarkable examination.  There was no VA Compensation and Pension evaluation in evidence.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP 10%, coded 5237 (lumbosacral or cervical strain), citing painful motion.  There was no VA rating decision.  The 10% rating was justified for the presence of painful motion.  The examinations noted the presence of muscle spasm, however, it did not result in an abnormal gait or spinal contour, thus the next higher 20% rating was not supported on this basis. 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 LBP.  

BOARD FINDINGS: In the matter of the LBP 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 20150615, 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, AR20170002606 (PD201501098)

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 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