RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01208
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050715

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Light Wheeled Vehicle Mechanic, medically separated for “chronic back pain…,” with a disability rating of 10%.  

CI CONTENTION:  The CI requests that all conditions be considered.  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 - 20050505	VARD - 20050831	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain…	5299-5242	10%	DDD, Lumbar Spine	5242	10%	20050512	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began in September 2004 after heavy lifting.  Radiographic evaluation (MRI) in February 2005 showed two bulging discs at the L4-L5 and L5-S1 vertebral levels.  At a neurosurgery evaluation in February 2005, the physical examination showed a normal gait, and full range of motion (ROM), without pain.  Provocative testing for nerve root impingement was negative.  The examiner concluded with a diagnosis of lumbar disc degeneration without recommendation for surgery.  Despite conservative 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 “chronic low back pain due to degenerative disc disease” for PEB adjudication.  

At the MEB NARSUM examination on 2 March 2005 (4 months pre-separation), the CI reported chronic pain worsened by exercise, and limited lifting to 20 pounds.  Physical examination showed a normal gait, tenderness and spasm of the paralumbar muscles.  Provocative testing for radiculopathy was negative, and neurologic examination showed no significant abnormalities.  Thoracolumbar flexion was to 90 degrees (normal) and the combined spinal ROM was 220 degrees (normal 240) without evidence of painful motion.  

At the 12 May 2005 VA Compensation and Pension (C&P) evaluation (2 months pre-separation), the CI reported low back pain exacerbated by activity and denied incapacitating episodes within the previous 12 months.  Physical examination showed normal posture and gait, and no evidence of tenderness or spasm.  Provocative testing for nerve root impingement was negative.  ROM was recorded as flexion to 80 degrees with painful motion and combined ROM greater than 200 degrees.  Repetition resulted in pain and additional limitations, however no measurements were documented.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated 10% for the low back condition analogously coded 5299-5242 (degenerative arthritis of the spine), citing tenderness, a normal combined ROM, and no evidence of neurologic abnormality.  The VA also rated 10% for the “degenerative disc disease lumbar spine,” coded 5242, and based on the C&P examination 2 months pre-separation, citing limitation of motion.  

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, as reported on the NARSUM and VA examinations.  Although muscle spasm was reported at the NARSUM examination, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% 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 low back condition.  

BOARD FINDINGS:  In the matter of the chronic back pain 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 20150610, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

08 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001927 (PD201501208)

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, I 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