RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01267
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051228

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

CI CONTENTION:  The CI’s condition continues to worsen and negatively impacts daily activities.  Additionally, the CI contends two mental health conditions not identified by the MEB/PEB.  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 - 20050916	VARD - 20060215	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Post-Traumatic Changes, Coccyx	5299-5010	0%	20051012	
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 low back condition began as early as January 2003, and was exacerbated by a fall in June 2004.  Radiographic studies performed just after the fall were normal, though further study via a bone scan in November 2004 showed a probable healing fracture of the tip of the coccyx (the tailbone, or lowest segment of the spine).  Evaluation by physical medicine and rehabilitation concluded with diagnoses of coccydynia (lower back pain felt at the lowest bone in the spine) and lumbosacral strain, and recommended non-surgical treatment.   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 LBP for PEB adjudication.
During the MEB examination (recorded on DD Forms 2807 and 2808) dated 3 August 2005, 4 months prior to separation, the CI reported chronic LBP rated 6/10 in severity, aggravated by lifting, bending, prolonged standing (no more than 20 minutes), and long driving (no more than 45 minutes).  Physical examination showed positive test results for hip joint and coccyx pathology (Patrick’s test) and radiculopathy, and tenderness of the lower back.  Neurologic exam and gait were both normal.  At the physical therapy appointment the following week (9 August 2005) the examiner recorded ROM as flexion at 90 degrees (normal 90) and combined ROM at 205 degrees (normal 240), with ROM limited by pain.

At the 12 October 2005 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, the CI reported no history of persistent radiation of pain, and indicated the low back condition did not interfere with ordinary lifting, carrying, posture or gait.  She did report taking an opioid pain reliever (tramadol) as well as non-steroidal anti-inflammatory drugs (naproxen and acetaminophen).  Physical examination showed normal gait, posture, and neurologic exam.  ROM was recorded as flexion at 90 degrees and combined ROM at 240 degrees.  There was no change, or evidence of pain, lack of endurance, fatigue, or incoordination, with repetitive motion.  Provocative tests for nerve root impingement were negative for radiculopathy.  There was no spasm in the back, radiographic studies were normal, and the examiner concluded there was no pathology identified by the exam to render a diagnosis.

At the time of the physical therapy (PT) appointment on 26 April 2006, 4 months after separation, the CI reported low back pain rated 8/10 in severity, with difficulty sleeping and an inability to sit or stand for more than 20 minutes.  On examination, a decrease in the normal curvature of the spine was noted, along with tenderness of the back.  Neurologic exam was normal, and ROM was recorded as flexion reduced by 50%, with no combined ROM able to be determined due to lack of specific measurements and no record of some planes of motion.  Provocative testing for nerve root irritation was negative for radiculopathy.  On 8 May 2006, the primary care examination reported similar complaints, with physical examination revealing normal spinal curvature, normal gait, and normal neurologic exam.  The back was tender, and ROM was recorded as “full.”  Provocative testing for nerve root irritation was negative.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP 10%, coded 5237 (lumbosacral strain), citing the presence of tenderness.  The VA rated the back 0%, and used the 5299-5010 code (analogous to arthritis, due to trauma), based on the VA C&P examination 3 months before separation, citing a lack of evidence of current pathology for the condition.  The Board agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT examination.  Tenderness, which also supported a 10% rating, was reported on the PT examination as well as the MEB 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 chronic low back pain.  

BOARD FINDINGS:  In the matter of the chronic low back pain and IAW VASRD §4.71a, the Board 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 20150611, 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, AR20170002458 (PD201501267)

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