RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01589
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050425

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated  for “chronic low back pain [LBP],” with a disability rating of 10%.

CI CONTENTION:  The CI contends his back condition continues to be problematic and since his separation from the service he has been diagnosed with PTSD.  The CI’s 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 - 20050211	VARD - 20050915	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	10%	Central Disc Bulge L3-4; L4-5; with Minimal Central Stenosis and Mild Degenerative Changes LBP	5243	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic 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 December 2003 after falling.  Radiographic studies showed degenerative disc disease with herniation of intervertebral discs at L3-4 and L4-5.  Evaluation by neurosurgeon recommended conservative treatment.  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 an MEB.  The MEB forwarded “chronic low back pain” for PEB adjudication.

The orthopedic examination on 7 September 2004, 8 months prior to separation, noted the CI reported “100% LBP” with associated spasms 30 times a week.  He was “unable to run, jump, ruck, march, [or] tolerate prolonged [sitting and standing].”  The examiner noted the back pain was 100%.  On examination there was tenderness in the lower back and pain with “extremes of ROM” [range of motion].  His gait, motor strength and sensation were normal.  Examination tests for radicular symptoms were negative.  The CI reported pain with examination maneuvers (3/5) not expected to elicit pain based on the known pathology.

The MEB examination (recorded on the DD Forms 2807 and 2808) and the MEB NARSUM examination were performed by the same physician on the same date and are combined below.  At the examination on 9 November 2004, 6 months prior to separation, the CI complained of chronic LBP with numbness and tingling of both lower extremities, greater on the right for the past 4 months.  Physical examination showed tenderness.  His gait, motor strength, reflexes, and sensation were normal.  Examination tests for radicular symptoms were negative.  The CI reported pain with 2 examination maneuvers not expected to elicit pain based on the known pathology.  The examination was silent in regards to ROM testing.

Thoracolumbar ROM measurements performed by physical therapy on 3 January 2005, 4 months prior to separation showed flexion of 50 degrees (normal 90) and combined ROM of 145 degrees (normal 240), after 3 repetitions.  There was pain with all movements and numbness in the left calf with extension.  There was no VA Compensation & Pension (C&P) exam in the casefile because the CI did not attend his scheduled C&P examination on 23 June 2005.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing tenderness and painful motion without focal neurological deficits.  The VA rated the back condition 0% coded 5243 (intervertebral disc syndrome (IVDS)) because the CI failed to attend the scheduled VA C&P examination.  The Board majority agreed that a 20% rating, but no higher, was justified for limitation of flexion greater than 30 degrees but not greater than 60 degrees reported on the physical therapy ROM study.  Although the CI had intervertebral disc syndrome, there was no evidence of incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 20% for the back condition, coded 5242.

BOARD FINDINGS:  In the matter of the back condition, the Board majority recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The single voter for dissent recommended no change and did not elect to submit a minority.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5243	20%	

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

XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.

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.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,
Enclosure