RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01716
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E5, Motor Transport Operator, medically separated for “chronic back pain,” with a disability rating of 0%.

CI CONTENTION:  The CI’s condition continues to worsen and negatively impacts his daily activities 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 - 20040209	VARD - 20070731	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	0%	Degenerative Joint Disease Lumbosacral Spine and Invertervetral Disc Disease L4-5	5237	10%	20070111	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain condition began in April 2003 after driving and climbing in and out of military vehicles during deployment.  The CI reported back pain since childhood with strenuous activities and X-rays showed spina bifida occulta (vertebral column defect without protrusion of neural elements) and spinal column degenerative changes (spondylolysis) with instability at L5-S1 (spondylolisthesis).  The CI was medically evacuated.  He reported constant low back pain with exacerbations and right lower extremity radiation with numbness and tingling.  Magnetic resonance imaging of the lumbar spine showed spina bifida occulta at L5-S1, degenerative disc disease with neuroforaminal (exit space for the spinal nerve) narrowing, and L5-S1 facet fracture.  Electrodiagnostic studies of the right lower extremity showed no evidence of radiculopathy.  Serial exams in record between August and November 2003 noted near normal range of motion (ROM) described as “full ROM w/minor pain,“ “↓flexion to~80°,” “ROM intact,” “lumbar ROM WNL,” and “↓ROM in extension.” and normal lower extremity strength, sensation, and reflexes were noted when addressed.  The CI was not considered a surgical candidate and facet joint or epidural steroid injections were recommended, but the CI declined injections at the time.  The MEB forwarded “chronic lower back with degenerative disc disease, degenerative joint disease, and congenital spina bifida of L5-S1 vertebrae” for PEB adjudication.

The MEB NARSUM examination in February 2004 (during the month of separation) noted complaints of daily low back pain.  The pain was made worse by standing, lifting, sitting and driving a military vehicle.  Physical examination showed normal gait and stance.  There was no tenderness, but here was increased pain with flexion.  Lower extremity strength, sensation, and reflexes were normal and testing for radiculopathy was negative.  Physical therapy performed ROM measurements for the MEB on 27 January 2004 and measured lumbar spine ROM.  Lumbar flexion was 60 degrees (normal lumbar flexion approximately 60 degrees).  The therapist noted guarding with some passive ROM.  

At the 11 January 2007 VA Compensation and Pension (C&P) evaluation, performed 35 months after separation, the CI reported daily constant back pain, with radiating pain usually to the right lower extremity, but occasionally to the left.  The CI reported no periods of incapacitation or missed work.  Physical examination showed normal posture and gait.  There was no tenderness, muscle spasm, atrophy, guarding, or weakness.  Thoracolumbar ROM was flexion of 90 degrees (normal 90), with painful motion noted and combined ROM was 240 (normal 240).  There was no additional loss of motion with repetitive use.  Lower extremity strength, sensation, and reflexes were normal.  Lumbar MRI in March 2006 showed degenerative disc disease at multiple levels, disc herniation at L4-5, and probable discitis at L5-S1, without evidence of nerve root compression.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5237 (lumbosacral strain), citing ROM limited by pain and no tenderness.  The PEB also indicated the condition existed prior to service but was eligible for compensation as the CI had over 8 years of active duty.  The VA rated the back condition 10% coded 5237, based on the VA C&P examination 35 months after separation, citing objective evidence of painful motion.  The Board agreed that a 10% rating, but no higher, was justified for the presence of painful motion and limitation of motion.  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.  Although the CI had intervertebral disc disease there was no documentation of incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic back pain condition, coded 5237.  

BOARD FINDINGS:  In the matter of the chronic back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

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 Back Pain	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150619, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005115, 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