RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01746
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cable Systems Installer Maintainer, medically separated for “chronic non-radiating low back pain,” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention.  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 upon a 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 - 20041101	VARD - 20150120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Non-Radiating Low Back Pain …	5299-5237	0%	Lower Back Injury	5237	NSC	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Low Back Pain, Non-Radiating.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began in January 2004 while lifting and moving heavy equipment.  A year later in January 2004 the CI was involved in another lifting injury.  Following the second injury, the CI had constant low back pain with tingling symptoms in his left lower extremity.  There was no surgical indication and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “mechanical low back pain” for PEB adjudication.  

An MRI in September 2004 was normal.  At the time of the physical therapy clinic appointment on 21 September 2004, gait was within normal limits and range of motion (ROM) was recorded as flexion of 90 degrees (90 normal), extension of 15 degrees (30 normal) and bilateral side bending was 30 degrees (normal 30), for a combined 225 degrees (240 normal).  The physical therapists stated the CI was not a rehabilitation candidate due to 5/5 Waddell signs (non-physiologic findings).  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated October 2004, 2 months prior to separation, the physical examination showed a normal gait.  The CI was able to heel-toe walk and jog and jump without difficulty, landing equal without pain.  ROM after repetition was flexion of 100 degrees and a combined ROM of 210 degrees.  

At the MEB NARSUM examination on 19 October 2004, 2 months prior to separation, the CI reported daily, constant throbbing low back pain, rated 5/10 that increases to 8/10 with an occasional tingling sensation in the left leg when lifting.  The CI reported he had no relief from therapy and his pain had not increased or decreased while on profile.  On examination, the CI had a normal gait with a slight increased lumbar lordosis.  ROM was flexion of 100 degrees with extension and bilateral side bending of 20 degrees (normal 30 degrees).  The combined ROM was incomplete (combined ROM could have been no greater than combined 235 degrees).  The CI failed to report to his 3 May 2005 VA Compensation and Pension (C&P) evaluation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the non-radiating back pain 0%, coded 5299-5237 (lumbar spine strain), citing full ROM, no signs of radiculopathy and no paraspinal muscle tenderness.  The VA did not service connect the back condition, citing a missed examination and no submitted evidence of continuity of symptoms or treatment from separation from service.  

The Board agreed that a 10% rating, but no higher, was justified for the combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT and ME exanimations.  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.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an additional disability rating was not justified on this basis.  

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 low back condition, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the low back condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5237 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	
Low Back Conditions	5299-5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150605, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

20 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001939 (PD201501746)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA