RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01528
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060404

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantryman, medically separated for “chronic low back pain [LBP]…,” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention.  The 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 - 20060302	VARD - 20150223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP Without Neurological Deficit	5239	0%	Back Condition	5237	NSC	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

LBP.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed LBP after a motor vehicle accident in July 2005.  Imaging (MRI) demonstrated degenerative changes with “minimal” spondylolisthesis (slippage of one vertebra over the other, L5 over S1 in this case), but no significant disc disease or nerve impingement.  There was no STR documentation of radicular symptoms or abnormal neurological findings.  Grossly normal range of motion (ROM), albeit with painful motion, was noted in one STR entry; but, a moderate limitation of flexion (to knees only) was described in another.  There was STR confirmation of a normal gait, no mention of abnormal spinal contour, and no documentation of incapacitating episodes.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for an MEB which in turn forwarded “spondylolisthesis grade one” to the PEB.

The NARSUM examination on 29 January 2006 (2 months before separation) documented back pain rated “slight and frequent” without note of radicular symptoms, and listed only profile restrictions as functional limitations.  The examiner referenced findings in the DD Form 2808 MEB physical examination which were marked as normal (including neurological) except for limitation of lumbar spine motion by pain.  The NARSUM referenced goniometric ROM measurements by physical therapy (20 December 2005) that documented flexion to 65 degrees (normal 90) with a combined ROM of 200 degrees (normal 240), specifying painful motion.  

The CI failed to report for a scheduled VA examination, and there was no temporally probative post-separation evidence.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated 0%, coded 5239 (spondylolisthesis), citing ROM limitation by pain, consistent with application of Army Regulation (AR) 635-40 (B-29, e).  Both the service ROM evidence and amply documented painful motion supported a rating of 10% IAW VASRD §4.71a.  There was no evidence for abnormal gait or spinal contour to support a 20% rating, no evidence for ratable peripheral nerve impairment that would provide for additional rating, and no documentation of incapacitating episodes or diagnosis of intervertebral disc syndrome that would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the lumbar spine condition under code 5239.

BOARD FINDINGS:  In the matter of the lumbar spine condition, the Board unanimously recommends a disability rating of 10%, coded 5239 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Degenerative Spondylolisthesis, Lumbar Spine	5239	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

20 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001283 (PD201501528)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA