RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01921
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060616

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E4, Health Care Specialist, medically separated for “chronic back pain,” with a disability rating of 0%.  

CI CONTENTION:  “Zero percent rating at discharge for back injury should be re-evaluated:  continued pain from injury.”  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 - 20060427	VARD - 20070601	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5237	0%	Residuals, Herniated Disc,…	5237	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was first evaluated for back pain on 18 June 2004 when she reported a 3 day history of low back pain (LBP) after carrying a rucksack for the prior few weeks.  The CI denied any specific injury or trauma and had an unremarkable examination.  She was treated with medications and duty restrictions.  She was next seen in the emergency room (ER) one year later for recurrent LBP and again several weeks after that.  An X-ray was remarkable for muscle spasm, but without evidence of degenerative joint disease (DJD) or degenerative disc disease (DDD).  An MRI on 24 August 2005 did show DDD at L5-S1 with possible impingement of the left S1 nerve root.  At an encounter in the ER on 19 September 2005, she again noted LBP and was placed on quarters for 48 hours.  The CI was evaluated in the spine clinic on 31 October 2005 and noted to have pain which radiated down the left leg.  Non-surgical management and MEB were recommended.  The CI was evaluated in physical therapy (PT) for range of motion (ROM) measurements on 26 January 2006.  Flexion was normal at 90 degrees, but the combined ROM reduced at 225 degrees (VA normal is 240).  Motion was limited by pain.  Her gait was abnormal with an exaggerated heel strike and restricted trunk motion.  Motor function was restricted in the lower extremities.  The reflexes were normal.  The examiner did not document the presence of tenderness, spasm, guarding, or an abnormal spinal contour.  The MEB NARSUM examination on 21 November 2005, 5 months prior to separation, noted complaints of chronic back pain aggravated by activity.  She took no medications as they had not proven effective.  The physical examination showed that the CI walked slowly with an antalgic gait, but could heel and toe walk.  She had no tenderness to palpation but had a positive straight leg raise.  The ROM mirrored the PT evaluation above.  Motor function and reflexes were normal.  Tenderness was present.  The examiner did not document the presence of spasm, guarding, or an abnormal spinal contour.  The MEB on 14 February 2006 determined that the LBP failed retention standards.  The CI non-concurred in a letter dated 16 February 2006 and noted “…my current profile is not indicative of the amount of physical activity I am capable of…”  She requested a referral for a medical evaluation.  On 28 February 2006, she non-concurred with the MEB findings and stated that she thought her LBP was medically acceptable.  She also noted substantial improvement since referred into the MEB process the previous December.  There was no VA Compensation and Pension evaluation in evidence.  

The Board directed attention to its rating recommendation based on the above evidence.  The Informal PEB on 7 April 2006 rated the chronic back pain condition 20%, coded analogously 5299-5237 (lumbosacral strain), citing pain limited motion and an antalgic gait.  The CI disagreed and requested a Formal hearing.  On 27 April 2006, the Formal PEB adjudicated the back pain as unfitting, rated 0% and coded 5299-5237.  The CI did not concur, but did not submit a rebuttal.  The US Army Physical Disability Agency (USAPDA) then reviewed and upheld the Formal PEB adjudication.  The VA service connected the chronic back pain condition and rated it 0%, coded 5237 STRs.  The non-compensable rating was assigned as the CI did not report for the scheduled VA evaluation.  A 10% rating is supported by tenderness, painful motion, and the limitations in motion documented.  Although there was an abnormal gait, neither spasm nor guarding were documented to support a 20% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a 10% rating coded 5237.  

BOARD FINDINGS:  In the matter of the chronic back pain condition, the Board unanimously recommends a disability rating of 10%, coded 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	
Chronic Back Pain	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150706, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170005294, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure