RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01395
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20031215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Unit Supply Specialist, medically separated for “chronic low back pain” with a disability rating of 10% 

CI CONTENTION:  The CI indicates she would prefer to present in person the issues why the rating should be changed.  Her 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 upon a 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:  

IPEB - Dated 20031010	VA* - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP without Neurologic Abnormality	5299-5237	10%	Mechanical LBP	5299-5237	10%	STR	
Other MEB/PEB Conditions x 0 	Other x 0	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20040113 (most proximate to date of separation [DOS]).  

Low Back Pain Condition.   According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in November 2001 after falling down some wet stairs and “hitting her lower back.”  Radiographic studies available in evidence report a normal lumbar and lumbosacral spine (one X-ray and one MRI each in 2003).  Electrodiagnostic studies (EMG/NCV) were not available in evidence, though no physical examination in the record reported radiculopathy and it was specifically denied in multiple examinations.  There was no surgical indication.  The MEB NARSUM examination on 29 July 2003 (4 months prior to separation) noted complaints of low back pain as well as “some tingling in her legs while sitting.”  Physical examination reported hypersensitive paraspinal muscles (the muscles that run along the spine), normal heel-toe walk without foot drop (foot drop is a result and indicator of spinal nerve impingement), and negative straight-leg raise (also a test for nerve impingement).  There was a negative Patrick’s (FABER) test (a test to assess pathological conditions of the sacroiliac or hip joint) and reflexes in the legs were normal bilaterally.  Neurologically, strength was normal and sensation was intact in the bilateral lower extremities.  At the MEB examination dated 1 August 2003 (4 months prior to separation), the CI reported recurrent back pain, with numbness or tingling when sitting, on the self-reported history (DD-2807-1, Report of Medical History).  Physical examination reported all systems relevant to this case as “normal.”  

The range-of-motion (ROM) performed by physical therapy on 8 October 2003, 2 months prior to separation, was used for rating by both the PEB and the VA.  In this examination, forward flexion was 65 degrees (rounded from 66 degrees IAW VASRD §4.71a) and the combined thoracolumbar ROM measurements totaled 195 degrees (normal 240).  It was unclear whether these measurements were performed with a goniometer (as specified by the VASRD) or an inclinometer.  

No VA Compensation and Pension (C&P) examination was performed proximate to the date of separation.  The VA rating decision used the service treatment records.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10%, coded analogously as 5299-5237 (lumbosacral strain), citing limitation of motion with pain and local tenderness.  The VA also assigned a 10% rating using the same code based on evidence in the STR, citing limitation of forward flexion.  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) as reported on the PT examination.  The presence of tenderness without associated gait or spinal contour abnormality also supports a 10% rating.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of incapacitating episodes which would provide for a higher rating under that formula.  The Board considered if there was evidence to support any separate peripheral nerve rating at separation.  Although the CI experienced episodic numbness, there was no objective evidence of a radiculopathy, fixed neurologic deficit or functional impairment with a direct impact on fitness.  The Board therefore concludes that 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 condition.  

BOARD FINDINGS:  In the matter of the low back 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX AR20160014397 (PD201501395)

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