RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01889
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020903

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Air Traffic Controller, medically separated for “chronic mechanical low back pain secondary to sources in the posterior lumbosacral and sacroiliac ligaments,” with a disability rating of 10%.  

CI CONTENTION:  “Mechanical lower back pain.”  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 - 20020508	VARD - 20020914	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical Low Back Pain Secondary to Sources in the Posterior Lumbosacral and Sacroiliac Ligaments	5299-5295	10%	Mechanical Low Back Pain	5295	10%	20020625	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Mechanical Low Back Pain.   According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic mechanical low back pain condition began in October 2000 after running during unit physical training. (PT).  X-rays of the lumbar spine were within normal limits. Surgery was not indicated. 

The 12 December 2001 MEB consultation NARSUM examination, 8 months prior to separation, noted complaints of chronic low back pain that was constant and dull in nature.  The pain was exacerbated with running, jumping, lifting greater than 15 pounds, and alleviated by rest only.  The CI denied experiencing weakness, bowel or bladder incontinence, or loss of sensation.  Physical examination showed a normal appearing spine, and a normal gait.  There was tenderness to palpation of the lower spine, and evidence of neurological deficits was absent and muscle strength was normal in bilateral lower extremities.  Range of motion was not addressed.

At the 25 June 2002 VA Compensation and Pension (C&P) evaluation, performed 2 months prior to separation, the CI reported she had intermittent bouts of non-radiating low back pain that was aggravated by prolonged standing, sitting, and prolonged walking or lifting.  Physical examination showed normal gait and posture, and tenderness over the sacroiliac joint and at L4-5 on palpation.  Musculoskeletal strength was normal and neurological function was intact.  ROM recorded flexion to 80 degrees with painful motion.   

The panel directed attention to its rating recommendation based on the above evidence.  The 2002 Veterans’ Administration Schedule for Rating Disabilities (VASRD) was in effect at the time of separation (DOS).  The 2002 standards for rating based on range of motion (ROM) impairment were subject to the rater’s opinion regarding degree of severity, whereas the current standards specify rating thresholds in degrees of ROM impairment.  The PEB rated the chronic mechanical low back pain secondary to sources in the posterior lumbosacral and sacroiliac ligaments condition 10%, coded 5299-5295 (Lumbosacral strain), citing pain with motion.  Likewise, the VA used the same code for a 10% rating based on painful and limited motion.

The panel agreed that a 10% rating, but no higher, was justified based on the evidence.  There was no path to a higher rating under any applicable code (5292 [LOM] or 5393 [intervertebral disc syndrome]) since ROM documented in the  C&P examination did not rise to moderate degree of limitation of motion, and clinical evidence of weakness and loss of neurological functioning was absent.  There was no documented muscle spasm that would justify the 20% rating under the 5295 code.  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 chronic low back pain condition.  

BOARD FINDINGS:  In the matter of the chronic mechanical low back pain condition and IAW VASRD §4.71a, the panel 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150617, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009248, 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