RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2015-01568
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050520

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for “chronic low back pain [LBP]” with a disability rating of 10%.  

CI CONTENTION:  The CI has consistent back pain and loss of feeling in hands and feet.  The 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 Board 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 determination 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(s) 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 - 20050502	VARD – 20051018	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5236	10%	Bilateral Sacroiliac Joint Dysfunction	5236	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic LBP.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in August 2004 after she fell on the obstacle course during basic training.  A bone scan performed on 26 October 2004 showed increased uptake in the left sacroiliac joint (SI) joint consistent with left sided sacroiliitis.  Lumbar spine X-rays on 9 November 2004 showed possible straightening of the normal lumbar lordosis with no compression abnormalities or subluxations and no spondylolysis (no degenerative changes).  Examiner noted the straightening “may be positional in nature.”  

The 3 December 2004 orthopedic examination documented full active range of motion (ROM) of the back without deformities, defects, step off, or point tenderness to palpation, and recorded no acute distress.  The 7 January 2005 follow-up orthopedic clinic evaluation indicated the CI’s pain had stabilized with prescriptions.  Full active ROM of the CI's back was recorded with no defects or tenderness.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “bilateral sacroiliac joint dysfunction” for PEB adjudication.  

The 18 April 2005 MEB NARSUM examination, 1 month prior to separation, noted complaints of daily, constant, dull pain in the bilateral sacroiliac joints, which increased to sharp pain with certain movements.  Physical examination showed normal gait and bilateral tenderness to palpation, right greater than left.  There was painful motion with back flexion of 85 degrees (normal 90) and combined ROM of 235 degrees (normal 240).  

There was no VA examination in evidence proximate to separation; however, X-rays taken by the VA on 25 May 2005, 4 days after separation, showed preservation of vertebral body height with little significant degenerative change and no gross compression deformities.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic LBP condition 10%, coded 5236 (sacroiliac injury and weakness) citing bilateral tenderness to palpation.  The VA rated the chronic bilateral SI joint dysfunction condition 0% coded 5236, citing no information from a missed examination.  In this case, the LBP and the sacroiliac joint dysfunction are closely related conditions.  In accordance with VASRD §4.66 (sacroiliac joint) which stipulates “The lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes,” the panel considered the LBP and sacroiliac dysfunction together for fitness and rating determinations.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees), or painful motion and tenderness, reported on the MEB examination a month prior to separation.  There was no muscle spasm 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.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic LBP condition.  

BOARD FINDINGS:  In the matter of the chronic LBP condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are 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 20150622, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009541, 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,					       
						      					
Enclosure