RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01479
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020801

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, SIGINT Analyst, medically separated for “chronic low back pain…” with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention.  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 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 - 20020619	VARD - 20020916	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5299-5295	10%	Degenerative Disease of the Lumbar Spine…	5293	10%	20020318	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation.  The Board noted that the 2002 Veteran Administration Schedule for Rating Disabilities (VASRD) standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The Board must correlate the above clinical data with the 2002 rating schedule; applicable diagnostic codes include: 5292 (limitation of lumbar spine motion); 5293 (intervertebral disc syndrome); and 5295 (lumbosacral strain).  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain (LBP) condition began in approximately 1999 following increased activity without a specific injury.  She was next seen in early 2001 and reported acute back pain which was treated with medications.  Her pain persisted and an X-ray showed a slight slippage of L5 on S1 associated with lumbar spine degenerative disc disease (DDD) and degenerative joint disease (DJD).  She was referred to orthopedics and issued a permanent L3 profile.  Repeat X-rays were similar.  She was also referred to physical therapy and taught proper back hygiene, but without improvement.  An MRI on 22 January 2002 showed a disc protrusion at L4-5 suggestive of a herniation; however, nerve root impingement was absent.  She was seen in physical medicine on 12 February 2002 and noted to have full range of motion (ROM).  Extension and recovery from flexion were painful.  The neurological examination was normal.  A steroid injection was not beneficial.  X-rays of the thoracic spine showed some spurring (DJD).  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 21 February 2002, 5 months prior to separation, the CI reported ongoing LBP.  On examination, she was noted to be tender to palpation over the lower lumbar area, but with normal reflexes and strength.  At the VA Compensation and Pension (C&P) evaluation performed on 18 March 2002, 4 months before separation, the CI reported thoracic back pain which was associated with lifting and pushups.  She also reported that the LBP radiated to her legs.  Tenderness was present over the upper thoracic and lumbar spine.  The ROM was full but painful.  The gait and reflexes were normal.  The MEB NARSUM examination on 11 June 2002, 1 month prior to separation, noted the above and cited the VA C&P physical examination.  Review of the records in evidence did not show any periods of incapacitation from the back condition in the year prior to separation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5299-5295 (analogous to lumbosacral strain), citing full but painful motion and radiculitis without radiculopathy (inflammation of the nerve roots as opposed to symptoms from compression of the nerve roots).  The VA rated the low back condition 10% coded 5293 (intervertebral disc syndrome), for limited and painful motion.  The CI was also service connected for DJD of the thoracic spine, coded 5291 (limitation of motion of the dorsal spine), as tenderness was noted on the C&P examination and X-ray findings of DJD.  However, it was noted that motion was full and pain free.  The gait and neurological examinations were also normal.  Incapacitation was not documented.  The ROM was full, but painful.  No route to a higher rating than the 10% adjudicated by the PEB for the chronic low back pain condition was found.  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 condition.  

BOARD FINDINGS:  In the matter of the LBP 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 20150617, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006602, 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,					       
						      					
Enclosure