RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01580
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050305

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Military Policeman, medically separated for “non-radiating low back pain,” with a disability rating of 10%.

CI CONTENTION:  The CI states that his back continues to worsen and he also has “massive headaches.”  The CI’s 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 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 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 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 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 - 20050118	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Non-Radiating Low Back Pain	5299-5237	10%	No VA Examination in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Non-Radiating Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in June 2000.  The CI denied any specific injury or trauma.  The 4 January 2003 lumbar spine magnetic resonance imaging (MRI) study, and 15 December 2003 lumbosacral spine and sacroiliac (SI) joint X-rays, were normal.  

At the MEB NARSUM examination on 15 December 2004, 3 months prior to separation, the CI reported that “his pain [was] always present, and worsened with activities that [required] running, jumping, use of gear (LCE, body armor, helmet), prolonged sitting, and lifting.”  The 2-7/10 pain was improved with stretching and rest.  There was no bladder/bowel dysfunction, saddle paresthesia (abnormal sensation, tingling, burning, prickling), or radiculopathy (nerve root irritation or injury).  The back examination showed range of motion (ROM) measurements of 65 (90 normal) degrees of flexion and combined ROM of 135 (240) degrees.  The CI had tenderness to palpation of the lumbar spine paravertebral muscles, but no muscles spasm.  There was no palpable defect, erythema (redness), edema (excess tissue fluid swelling), or ecchymosis (bruising).  Strength, sensation, pulses, and deep tendon reflexes (DTRs) were normal.  There was no VA examination in evidence proximate to separation

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5237 (analogous to lumbosacral strain), citing limitation of forward flexion to 65 degrees.  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 reported on the MEB NARSUM examination proximate 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 (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  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 back condition.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150623, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170008541, 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.