RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2015-01824
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050328

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E5, Armor Crewman, medically separated for “back pain with degenerative disc disease,” with a disability rating of 10%.

CI CONTENTION:  The CI makes no contention.  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 – 20041206	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	
Back Pain with Degenerative Disc Disease…	5239	10%	No VA Examination in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Back Pain with Degenerative Disc Disease.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered a duty-related strain injury to his back in August 2003.  Imaging (MRI) demonstrated degenerative disc disease (“mild” at L4/5, Grade I spondylolisthesis at L5/S1, no herniation or neural encroachment).  The pain improved, but recurred during training after his unit was mobilized in April 2004.  There was no STR documentation of radicular symptoms, and there were multiple normal neurological examinations in evidence with none to the contrary.  Earlier entries indicated significant range of motion (ROM) limitation, but this improved over time.  There was STR documentation of normal gait and spinal contour with no contrary entries, and there was no STR documentation of incapacitating episodes.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for MEB.

The 18 October 2004 MEB NARSUM examination, 5 months prior to separation, documented persistent back pain (rated 1/10 during ROM testing) without note of radiation or neurological symptoms, and without elaborating functional limitations other than profile restrictions.  The physical examination recorded a normal gait, the absence of spasm or tenderness, and normal neurological findings (5/5 strength, intact sensation, symmetric reflexes).  Measured ROM performed by physical therapy on the same day was reported in the NARSUM:  flexion to 90 degrees (normal 90) and combined ROM of 220 degrees (normal 240), specifying painful motion.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain condition 10%, coded 5239 (spondylolisthesis).  The PEB acknowledged the absence of a ratable neuropathy and was consistent with VASRD §4.71a criteria for the ROM and other ratable evidence. There was no ROM evidence supporting a rating higher than 10%, no evidence for abnormal gait or spinal contour to support a 20% rating, and no documentation of incapacitating episodes that would provide for a higher rating under that formula.  There was no evidence for peripheral nerve impairment in support of additional rating for associated 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 back pain condition.

BOARD FINDINGS:  In the matter of the back pain 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

AR20170009333  , XXXXXXXXXXXXXXXXXX 

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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