RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01308
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061023

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

CI CONTENTION:  The CI contends his rating is to low and his condition continues to prevent him from performing his daily activities.  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 - 20060911	VARD - 20070630	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back  Pain	5241	10%	Chronic Low Back Strain Postoperative Residuals	5237	10%	20070630	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery with an anterior/ posterior fusion in December 2005 for spondylolisthesis.  Radiographic evidence February 2006 post-surgery revealed no complications.  Range of motion (ROM) was slightly limited but there was no fracture or subluxation present.  A neurological examination performed on 2 May 2006 showed the CI had diffuse tenderness in his lower back without “trigger points or muscle spasm.” Flexion and Extension was slightly limited by pain.  Straight leg raise (SLR) testing was negative for radiating symptoms.  The CI displayed a normal gait, no paraspinal muscle spasm, normal reflexes, and normal strength.  Heel and toe walking was normal.  The diagnosis was “intervertebral disc degeneration herniated intervertebral disc of the lumbar spine, status post L5-S1 fusion and chronic lumbago.”  The MEB forwarded intervertebral disc degeneration for PEB adjudication.  
During the April 2006, MEB examination (recorded on DD Forms 2807 and 2808) 6 months prior to separation, the CI reported chronic pain and difficulty ambulating.  He also reported numbness with pain radiating to both extremities.  Pain was aggravated by activity.  The physical exam showed severely limited ROM in flexion and extension.  The examiner stated limited mobility caused difficulty at home and in workplace.  He was unable to exercise due to surgery.  Neurological examination was grossly normal.  The CI also has difficulty sleeping due to back pain. Thoracolumbar range of motion (ROM) measurements performed by physical therapy (PT) on 13 June 2006 showed, after repetition, flexion of 90 degrees (normal 90) and combined ROM of 240 degrees (normal 240) after repetition.  

The 2 August 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of “aching with occasional stabbing pain.”  Pain was 3/9 over the prior week.  Pain was constant with varying intensity.  Pain was precipitated and exacerbated by lifting greater than 20 pounds, running, prolonged standing, prolonged walking, and twisting, bending and sexual activity.  Pain was alleviated by narcotic medication.  The CI endorsed “moderate sleep disturbance, mild effect on activities of daily living and difficulty driving over a certain distance.”  The physical examination from the NARSUM referenced the examinations (Neurosurgeon and physical therapy) and radiographic findings above.  The CI could not perform the duties of his MOS nor perform the Army Physical Fitness test (APFT).  His physical training consisted of the elliptical and recumbent bike.  The examiner stated the condition was stable but prognosis was poor for return to duty.  

At the 30 June 2007 VA Compensation and Pension (C&P) Spine evaluation, 8 months after separation, the CI reported persistent back pain worse on the left side.  He reported occasional shooting pain to his anterior thigh.  He reported pain when trying to lift his son.  He denied bowel and bladder incontinence.  Attempts at running caused severe pain and he had to stop after approximately three blocks.  He only took Aleve for pain.  The physical examination noted the CI displayed a normal gait and spinal contour, no paraspinal muscle spasm, normal reflexes, normal strength, and examination maneuvers for radicular signs were negative.  He had a well-healed, non-tender surgical scar.  The thoracolumbar ROM recorded active flexion to 75 degrees (normal 90), extension 30 degrees (normal 30), right lateral flexion 15 degrees (normal 30), left lateral flexion 25 degrees (normal 30), all limited by pain, and right rotation 45 degrees (normal 30), left rotation 45 degrees (normal 30) with no additional limitation with repetitive motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10%, coded 5241 (spinal fusion), citing pain limited motion.  The VA rated the chronic low back pain condition 10% coded 5237 (lumbar spine strain), based on the VA C&P examination 8 months after separation, citing flexion (greater than 60 degrees but not greater than 85 degrees) or combined ROM (greater than 120 degrees but not greater than 235 degrees).  Although there was insufficient limitation of motion to support a minimum rating on the NARSUM examination, the Board agreed a 10% rating was justified for the presence of painful 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) or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the VA 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 evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no associated radiculopathy for separate peripheral nerve rating.  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 was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an 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 low back pain condition.  

BOARD FINDINGS:  In the matter of the chronic low back pain 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, 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 20150614, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007463, 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