RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01109
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070504

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Patriot Fire Control Enhanced Operator Maintainer, medically separated “chronic back pain,” with a disability rating of 10%.

CI CONTENTION:  The CI’s rating was wrong and his condition continues to worsen.  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 - 20070405	VARD – 20070723	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	10%	Degenerative Disk Disease, Thoracolumbar Spine	5242	10%	20070430	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in February 2005 after he fell approximately 10 feet.  There was no surgical intervention.  Radiograph studies noted in the NARSUM detail the finding of degenerative spondylosis and degenerative disc disease in the mid-lower thoracic spine. Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “spondylosis” for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated January 2007, 4 months prior to separation, the CI reported popping of the bones in his spine and numbness in his feet after standing for a period of time or sitting for a few minutes.  Physical examination showed tenderness to palpation over the thoracic and cervical spine areas that worsened with motion.  

The MEB NARSUM examination on 26 January 2007, 4 months prior to separation, noted complaints of low back pain (aching, intermittent sharp, stabbing sensations) and popping of the spine.  Pain was rated 6/10, but increased with climbing and wearing of military gear.  Physical examination showed a normal gait and back examination without spasms or sensory deficits in either lower extremities.  Radiculopathy testing was negative.  There was lower extremity muscle strength.  Range of motion (ROM) was 70 degrees of forward flexion (normal 90) and a combined ROM of 180 degrees (normal 240).

At the 30 April 2007 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported pain localized to the lumbosacral area with occasional radiation to the left foot. The pain was rated at 7/10; however, 9/10 exacerbations with bending, lifting, running and activities of daily living occurred 4 times per week.  No incapacitation was reported.  The CI took OxyContin and Hydrocodone (narcotic pain medications) for pain relief.  Physical examination showed tenderness at T10-T11 and L3-L5 interspace with 2+ paraspinous muscle spasm.  Radiculopathy testing was (straight leg raise) was negative.  Radiographic studies detailed there was no discogenic disease or spinal stenosis.  ROM was forward flexion to 80 degrees.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5237 (lumbosacral or cervical strain), citing pain-limited motion without spasm or tenderness. The VA also rated the back condition 10% coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 3 months after separation, citing forward flexion.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM and VA examinations.  There was no documentation of incapacitating episodes which would provide for a higher rating.  Although the CI experienced radiating pain, there was no objective evidence of a radiculopathy or functional impairment with a direct impact on fitness.  While the CI may have experienced radiating pain from the back condition, 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 is no evidence in this case that there was radiculopathy with associated functional impairments separately functionally impairing.  The Board therefore concludes that additional disability rating was not justified 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 back condition.  

BOARD FINDINGS:  In the matter of the back 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 recommends 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

AR20170004784, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					       
						      					
Enclosure