RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01203
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “mechanical low back pain [LBP], insidious onset…,” with a disability rating of 10%.

CI CONTENTION:  Contends a rating higher than 0%.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20020507	VARD - 20100906	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical LBP, Insidious Onset	5295	10%	Back Condition	5237	10%	20100901	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Mechanical LBP, Insidious Onset.  The 2002 VASRD coding and rating standards for the spine, which were in effect at the time of permanent separation, were changed to the current §4.71a rating standards on 26 September 2003, following the CI’s permanent disability disposition.  The older ratings were based on a judgment as to whether the disability was mild, moderate or severe.  The current standards are grounded in range of motion (ROM) measurements.  IAW DoDI 6040.44, this panel must consider the appropriate rating for the CI’s back condition at separation based on the VASRD standards in effect at the time of separation.

According to the service treatment record the CI first experienced back pain in May 2000 after a wall locker fell on her, but chronic back pain developed after falling down some stairs in July 2001.   Diagnostic imaging studies (X-ray) in October 2001 showed a normal lumbar spine.  There was no surgical indication.  At an evaluation on 23 July 2001, (2 days after falling down the stairs and 1 year prior to separation) the CI reported constant, throbbing pain that radiated down the left leg.  Physical examination showed no spasm, but pain with active ROM was present.  A test for possible nerve root irritation was positive on the left.  A follow-up evaluation 1 week later noted constant pain that did not radiate.  Examination showed full ROM and no evidence of nerve root irritation.  A 17 October 2001 physical examination, 9 months prior to separation, noted normal back ROM with tenderness of paraspinal muscles.

On the 28 February 2002 MEB Report of Medical History (recorded on the DD Form 2807-1), 5 months prior to separation, the CI wrote that she had constant back pain since basic training and had used a back brace since July 2001.  During the 7 May 2002 narrative summary evaluation, 2 months prior to separation, the CI reported LBP aggravated by running, marching, jumping, riding in vehicles, and prolonged sitting.  There was no VA examination in evidence within the 12-month allowable window for adjudication.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the mechanical LBP condition 10%, coded 5295 (lumbosacral strain).  The VA initially rated the lumbar spine condition 10% under a newer spine code, 5237 (lumbosacral strain), but as previously elaborated the panel must use older codes in effect at the time of separation.  Moreover, the VA’s rating was based on an examination over 8 years after separation, which held no probative value in the panel’s deliberations.  The panel agreed that criteria supporting the next higher 20% rating under the 5295 code are not in evidence (i.e. “with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position”), but debated if a higher rating was supported under other codes in effect at the time of separation.  Under the 5292 code a 20% rating is justified for “moderate” limitation of lumbar motion, but based on the evidence at hand panel members concluded that this degree of limitation was not present.  Finally, there was no evidence of intervertebral disc syndrome to warrant a rating under the 5293 code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the mechanical LBP condition.  

BOARD FINDINGS:  In the matter of the mechanical LBP, insidious onset condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

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

AR20170007456, XXXXXXXXXXXXXXXXXX 

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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