RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01261
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080618

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, M1 Armor Crewman, medically separated for “chronic low back pain,” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  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 - 20080215	VARD - 20090729	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Thoracic Strain with Minimal Thoracic Scoliosis and Degenerative Arthritis of the Lumbar Spine and Spina Bifida Occulta S1	5242-5237	NSC	20090707	
Right Knee Pain	Not Unfitting	Patellofemoral Pain Syndrome, Right Knee	5260	0%	20090707	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

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 in a pre-service motor vehicle accident in May 2005 where he was treated for neck and upper back pain, but he didn’t start to have low back pain until August 2005 while in basic training.  Original radiographic studies showed spondylolysis (stress fracture of the lumbar spine) at L5-S1 and later studies showed straightening of the spine with S1 spinal dysraphysm (a congenital spinal defect).  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “low back pain – stable spondylolysis with normal exam” for PEB adjudication. 

The MEB NARSUM examination on 15 November 2007 (4 months prior to separation) noted complaints of non-radiating intermittent sharp low back pain that was aggravated by lifting heavy weight.  The CI denied numbness, tingling or weakness.  On examination the CI was noted to sit without any signs of discomfort for nearly an hour and was able to bend over and remove his socks and shoes without any signs of discomfort.  The CI had functional, pain-free lumbosacral range of motion (ROM) in all planes.  Examination tests for radicular symptoms were negative and his gait, motor strength, reflexes and sensation were all normal.  Thoracolumbar ROM measurements performed by physical therapy (PT) on 13 December 2007, 3 months prior to separation, showed, after repetition, flexion of 90 degrees (normal 90) and combined ROM of 220 degrees (normal 240).  The examiner noted that he used an inclinometer to measure flexion and extension, but used a goniometer for the other planes of motion.  He also noted that pain was present during the examination, but it wasn’t a limiting factor in the CI’s ROM.  The examiner noted the presence of tenderness and spasm, but no abnormal gait or spinal contour.   

At the 7 July 2009 VA Compensation and Pension (C&P) evaluation, performed 13 months after separation, the CI reported he was not having problems with his back.  The physical examination showed a normal posture and gait.  ROM was flexion of 90 degrees (90 normal) and a combined ROM of 240 degrees (240 normal).  There was no limitation by pain on motion, no tenderness and no spasms.  Motor, strength and reflexes were normal.   

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain).  The VA denied service connection for the back.  The Board agreed that a 10% rating, but no higher, was justified for limitation of combined ROM greater than 120 degrees but not greater than 235 degrees as reported on the MEB PT examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  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.  

Contended PEB Conditions:  Right Knee Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The Board notes that the contended condition was not profiled or judged to fail retention standards.  However the commander indicated that “simple tasks such as marching in formation or executing road guard [duties] stress his…knee.”  The MEB indicated that although the CI injured his right knee during Marine Corps basic training and was symptomatic while in the Army, his knee had never required profiling restrictions.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right knee condition, the Board unanimously agrees that it cannot recommend it for additional disability rating. 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 20150613, 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, AR20170002457 (PD201501261)

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