RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01745
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030307

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

CI CONTENTION:  The CI did not submit a contention on in the application.  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 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 - 20030124	VARD - 20030903	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5295	10%	Lumbosacral Strain	5295	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 suffered an atraumatic onset of back pain in March 2001.  Imaging demonstrated degenerative disc disease (L2-5, “mild” without significant neural encroachment).  Multiple STR clinical entries confirmed the absence of radicular symptoms and normal neurological findings (5/5 strength), with no contrary evidence.  Multiple STR entries documented grossly normal or marginally limited range of motion (ROM), although some specified painful motion; and, no entries documented any significant ROM limitation.  There were no STR entries that documented abnormalities of gait or posture and none that documented incapacitating flares of back pain.  A neurosurgery consultant opined that surgery was not indicated; conservative treatment did not result in improvement sufficient to allow unrestricted duty; and the CI was referred for MEB.  

The 18 December 2002 NARSUM examination, 3 months before separation, documented non-specific pain without radiation or neurological complaints that was “exacerbated by heavy lifting, bending, stooping, and reaching.”  The physical examination recorded a normal gait and spinal contour without note of tenderness or spasm, and normal neurological findings (5/5 strength, intact sensation, symmetric reflexes).  The examiner described anatomically normal ROM excursions other than extension limited to 10 degrees (normal 30).  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The 2003 VASRD coding and rating standards for the spine, which must be applied to the panel’s recommendation IAW DoDI 6040.44, differed significantly from the current §4.71a general rating formula for the spine.  The PEB rated the condition 10% rating coded analogous as 5295 (lumbosacral strain), citing pain with motion that was consistent with the 10% criterion of the “characteristic pain on motion” of code 5295.  The VA rated the condition 0%, coded 5295, based on the STR, citing “A noncompensable evaluation is granted for slight subjective symptoms only.”  

None of the criteria for a higher rating under code 5295 were in evidence.  The older code, 5293 (intervertebral disc syndrome), was neither clinically applicable nor favorable given the absence of evidence for “recurring attacks” requisite for a higher rating.  The only remaining code available in the 2003 VASRD subject to consideration was code 5292 (limitation of motion) that required at least “moderate” limitation to achieve a rating higher than the 10% conferred by the PEB; and, members agreed that the ROM evidence did not support a higher rating under that code.  There was no evidence in support of additional rating for spinal neuropathy.  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 of the lumbar spine condition.

BOARD FINDINGS:  In the matter of the lumbar condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are 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 20150629, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008866, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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