RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01355
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050119

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Bradley Fighting Vehicle System Maintainer, medically separated for “low back pain,” with a disability rating of 10%.

CI CONTENTION:  The CI’s condition continues to worsen and negatively impact his daily activities.  The CI’s 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 panel 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 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 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 - 20041208	VARD - 20060221	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain 	5238	10%	Mechanical Low Back Pain	5237	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in 2000 with no specific injury or trauma.  Magnetic resonance imaging (MRI) studies on 15 May 2004 revealed severe protrusion of lower lumbar disc with secondary spinal canal narrowing.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic low back pain with radicular symptoms” for PEB adjudication.  A physical therapy appointment on 7 April 2004, 10 months prior to separation, documented lumbar range of motion (ROM) as “within normal limits” without pain.  

During the 5 November 2004 MEB NARSUM examination (recorded on DD Forms 2807 and 2808), 3 months before separation, the CI reported a 6-7/10 low back pain that radiated to his left leg.  The pain was aggravated by prolonged sitting, standing, jumping, running, bending, or lifting.  The pain was partially relieved by sitting and or shifting weight off the left leg.  The CI endorsed the inability to perform physical training, field duties, and mechanic’s duties such as lifting, bending, and moving heavy machinery.  The physical examination noted “back; pain with ROM.”  There were no numeric ROMs documented.  A left straight leg raise was noted as positive for radiculopathy.  There was no VA Compensation and Pension examination in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain condition 10%, coded 5238 (spinal stenosis), citing tenderness and limited painful motion.  The VA also rated the low back pain condition 10%, coded 5237 (lumbar spine strain), citing no current evidence to warrant a higher rating.  Although there was insufficient clinical information on the limits of thoracolumbar motion to support a minimum rating, the panel agreed that a 10% rating was justified for the presence of painful motion.  Absent evidence of accompanying muscle spasms 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.  

BOARD FINDINGS:  In the matter of the low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were 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 20150615, w/attachments
Exhibit B.  Service Treatment Record

	

AR20170005998, 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,