RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01584
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Motor Transport Operator, medically separated for “mechanical low back pain” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  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 progression or complications of service-connected conditions after separation.  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 - 20070801	VARD - 20071204	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Low Back Pain	5299-5237	0%	Lumbago (Low Back Pain)	5237	NSC	20071105	
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	NSC		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Mechanical Low Back Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began in April 2005 after noticing nagging back pain while driving trucks in Iraq.  Over the course of his deployment, the pain became progressively worse.  Radiographic (X-rays) studies taken in April 2007 showed no acute disease.  Despite treatment, the CI’s condition did not improve sufficiently enough to allow for unrestricted duty.  

At the 13 March 2007 MEB examination (recorded on DD Forms 2807 and 2808), 5 months prior to separation, the CI reported recurrent back pain, and various symptoms unrelated to his back.
Physical examination showed mild tenderness to palpation over the lower lumbar region and “nearly full ROM.”

The 27 March 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of low back pain.  The CI stated his pain was aggravated by running, jumping, crawling, and repetitive lifting.  He was unable to perform the APFT run requirements because of the pain and he was unable to do sit-ups without experiencing and aggravating his pain.  Physical examination showed tenderness to palpation over the back muscles without evidence of muscle spasm.  Range of motion (ROM) measurements were recorded by physical therapy (PT) on 4 April 2007 and showed a normal flexion of 90 degrees and a normal extension of 30 degrees.  PT also recorded absence of gait abnormality, muscle spasm, guarding, sensory or motor deficits.

At the 5 November 2007 VA Compensation and Pension evaluation, performed 2 months after separation, the CI reported his back pain had continued.  He was not taking any pain medication, and was not using a back brace.  Lying flat on his back on the floor or doing stretches improved his back pain.  The CI denied any periods of incapacitation due to back pain.  Physical examination showed tenderness to palpation over the lumbar spine and absence of spasm.  ROM documented a normal flexion of 90 degrees and a normal extension of 30 degrees without evidence of pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain 0%, coded 5237 (lumbosacral strain), citing “no mechanical loss of motion IAW AR 635-40.”  The VA did not service connect the low back pain coded 5237, citing “lumbago (low back pain) is not considered an actually disabling condition.”
  
There was no limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine, and no documented evidence of painful motion or functional loss at the NARSUM, PT, or VA examinations.  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 low back pain.  

Contended PEB Condition:  Migraine Headaches.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the low back pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended migraine headache condition, the panel agrees that it cannot recommend it for additional disability rating.  There were 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 20150624, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170008545, 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,