RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01870
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040701

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Ammunition Specialist, medically separated for “chronic low back pain with thoracic and lumbar degenerative disc disease,” with a disability rating of 10%.  

CI CONTENTION:  “Consider all conditions.”  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 - 20040513	VARD - 20041028	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain with Thoracic and Lumbar Degenerative Disc Disease	5299 -5237	10%	Thoraco-Lumbar DDD with Lumbar Strain	5242	20%	20041004	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP) with Thoracic and Lumbar Degenerative Disc Disease (DDD).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began in 1998 without specific trauma.  He was diagnosed with thoracic and lumbar DDD with herniation without neural involvement.  There was no surgical indication.  

At the March 2004 MEB examination (recorded on DD Forms 2807 and 2808), 3 months prior to separation, the CI reported LBP.  
Physical examination revealed bilateral paraspinal muscle and midline tenderness at the L2-L5 vertebral levels.  The CI was able to squat but not duck walk secondary to LBP.  Nerve tension testing was negative.  Strength, sensory and reflex testing was normal.  The 1 April 2004 MEB NARSUM examination noted complaints of worsened pain with inability to lift more than 10 pounds, run or exercise.  The examiner quoted the MEB 2808 examination findings.  At a 25 April 2005 physical therapy (PT) visit, range of motion (ROM) measurements reported after three repetitions showed “normal flexion and extension.”  

At the 4 October 2004 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported constant pain worsened by physical activity, and limited ability to lift weight, stand and sit; and denied incapacitation or time lost from work.  Physical examination showed 60 degrees flexion (90 normal), limited by pain.  There was no evidence of tenderness, spasm, or radiation of pain on movement, however nerve tension testing was positive bilaterally.  There were no additional limitations from fatigue, weakness, or incoordination.  There was no evidence of intervertebral disc syndrome.  Lumbar spine X-ray studies were normal.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated 10% for the LBP coded 5237 (lumbosacral strain), citing normal flexion and no neurologic deficit.  The VA rated 20% for the LBP coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 3 months after separation, citing flexion to 60 degrees with normal neurologic and radiographic examinations.  

Although there was insufficient limitation of motion to support a minimum rating, the panel agreed a 10% rating was justified for the presence of painful motion as adjudicated by the PEB.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, and no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes, nor 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 LBP.  

BOARD FINDINGS:  In the matter of the low back pain 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 20150707, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20170009228, 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