RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01386
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030827

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

CI CONTENTION:  The CI made no specific contention.  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 - 20030714	VARD - 20040823	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic  Back Pain 	5299-5295	10%	Chronic Lumbar Pain Secondary to Compression Fracture	5236	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s condition began on 8 April 2002 after he sustained a back injury during an airborne operation.  Lumbar spine X-ray studies on 10 July 2002, revealed compression fractures of L3 through L5 and unrelated stable thoracic scoliosis was noted.  There was no surgical indication, and conservative orthopedic and physical therapy treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic lumbar pain secondary to compression fracture” for PEB adjudication.  

At the orthopedic MEB consult performed on 9 April 2003, the CI reported intermittent low back pain graded 3/10 with intermittent paresthesias (sensory disturbances) to the buttocks only.  He was taking no medication for the pain.  On the physical exam there was no tenderness to palpation.  Strength and sensation were normal and reflexes were symmetrical.  The examiner noted that X-rays showed healed, stable lumbar compression fractures, with mild anterior compression of less than 10%.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 2 May 2003, 4 months prior to separation, the CI reported he had not fully recovered from the compression fracture and suffered from “numbness and tingling.”  Physical exam showed no gross scoliosis to exam.  There was “minimal discomfort” on “finger tips to toes” forward flexion.  Lumbar spasm was noted and neurological exam was “intact throughout,” no muscle atrophy was noted and straight leg raise testing to elicit radicular symptoms was negative.  

The MEB NARSUM examination on 29 May 2003, 3 months prior to separation, noted complaints of chronic back pain which “mildly bothers him almost daily and is severely aggravated with any vigorous impact PT or exercise.”  The CI additionally reported that prolonged standing resulted in back spasms, increased pain, and limitation of motion.  Physical examination cited the same findings as the MEB examination summarized above.  The examination was noted to be otherwise normal.  Physical therapy measured range of motion (ROM) for the MEB on 9 May 2003 and forward flexion was 110 degrees (normal 90) and combined ROM was 240 degrees (normal 240).  Painful motion was noted.

The CI failed to present for a scheduled VA Compensation and Pension (C&P) evaluation. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain 10%, using code 5299-5295 (analogous to lumbosacral strain) citing “pain with motion” under VASRD spine rules in effect on the date of separation, which were changed to current VASRD rules effective 26 September 2003.  The VA rated the back pain 0% coded 5236 (Sacroiliac injury and weakness) in August 2004 using current VASRD coding and rating criteria.  The VA rating was based on the service treatment records citing the recorded ROM was insufficient for a rating.  The Board is required to a make a rating recommendation in accordance with the VASRD rules for rating the spine in effect on the date of separation.  There was evidence of “pain with motion” for a 10% rating coded as 5299-5295.  Although there was muscle spasm noted at the MEB examination, there was no evidence of loss of lateral motion (or any limitation of ROM) for the next higher 20% rating.  There was not sufficient evidence of limitation of motion for a higher rating based on limitation of motion alone. (5292)  There was also no evidence of intervertebral disc syndrome with incapacitating episodes of total duration of at least 2 weeks for higher rating coded as 5293 and there was no chronic orthopedic or neurological impairment for additional rating under other VASRD orthopedic and/or neurological codes.  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 back pain.  

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 20150619, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006012, XXXXXXXXXXXXXXXXXX. 

XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX

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,