RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01713
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20031106

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Automated Logistic Specialist, medically separated for “chronic lumbar and thoracic pain” with a disability rating of 20%.

CI CONTENTION:  Review of back pain, chronic cough, acid reflux and chronic migraines.  The CI also provided a personal memo that the panel reviewed in its deliberations.  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 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 - 20031106	VARD - 20031103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lumbar and Thoracic Pains…	5099-5003	20%	Mechanical Lumbar and Thoracic Low Back Pain	5237	10%	20030902	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Chronic Lumbar and Thoracic Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in February 1996 after a motor vehicle accident.  Imaging (X-ray and MRI) were unremarkable and back surgery was not indicated.  The MEB NARSUM examination on 15 April 2003, 7 months prior to separation, noted complaints of back pain minimally relieved by pain medication.  He was unable to run, wear body armor, do sit-ups, wear a rucksack, or lift greater than 20 pounds.  Physical examination showed spinal tenderness with goniometric-range of motion (ROM) of 70 degrees forward flexion (normal 90), 15 degrees extension (normal 30) and 35 degrees of right and left lateral flexion (normal 30).  The MEB NARSUM Addendum examination on 15 May 2003, 6 months prior to separation, also noted complaints of back pain minimally relieved by pain medication.  He was unable to perform basic soldiering skills.  Physical examination also showed spinal tenderness.  Sensory and neurological testing were within normal levels.  The goniometric-ROM equal the MEB NARSUM findings.  At the 02 September 2003 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported chronic back pain.  He was unable to run or perform military duties with slight difficulty going up and down stairs.  Physical examination showed spinal tenderness with normal major muscle groups (lower extremities) tone and strength; good toe and heel walking and normal tandem gait.  The goniometric-ROM was also equal to the MEB NARSUM findings. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain condition 20%, analogously coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA rated the back pain 10%, coded 5237 (lumbosacral strain) based on the C&P examination 2 months before separation, citing limitation of motion with pain on motion.  The STR and VA evidence insufficient for limitation of motion to support a rating higher than 20% granted by the PEB.  Additionally, there was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula 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 chronic lumbar and thoracic pain 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 20150701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008853, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX

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