RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01940
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve O3, Infantry Officer, medically separated for “low back pain” with a disability rating of 10%.

CI CONTENTION:  “Review 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 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 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 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 panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20030602	VARD - 20030923	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5295	10%	Degenerative Changes Lumbosacral Spine	5295	10%	20030728	
Left Knee Iliotibial Band Syndrome	Not Unfitting	Right Hip Strain	5399-5315	10%		
Right Shoulder Anterior Dislocations		History of Dislocation of the Right Shoulder	5203	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back.  According to Service treatment record (STR) and the medical evaluation board (MEB) narrative summary (NARSUM), the CI “had chronic low back pain for about 3 years without any specific precipitating event.  He has had intermittent exacerbations since the year 2000 usually after minor twisting movements.”  The 16 February 2003 lumbar spine magnetic resonance imaging (MRI) study showed an L5-S1 central disk extrusion without evident nerve root compression.  

At the 25 February 2003 MEB NARSUM, 7 months before separation, the CI complained of low back pain; however, he denied sensory symptoms into the lower extremities, significant radicular (nerve root irritation or injury) pain, and bowel or bladder dysfunction.  The physical examination revealed no evidence of lower extremity atrophy (wasting).  Strength and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  Sensation was normal except for “a patch of subjective hypesthesia [diminished sensation] at the medial aspect of the right knee.”  The straight leg raise ([SLR] assesses for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) tests were negative.  The diagnoses listed chronic diskogenic low back pain and degenerative lumbar disk disease.  

At the time of the 5 March 2003 physical therapy (PT) appointment for MEB range of motion (ROM) measurements, flexion was normal at 90 degrees, and combine ROM was 235 degrees (normal 240).  

At the 28 July 2003 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported low back pain since December of 2000 and denied “true radicular type of symptoms.”  Symptoms were exacerbated by prolonged sitting, prolonged standing, activity, running, torsion type motions, and heavy lifting.  The physical examination documented a slightly antalgic (assuming a gait or posture to lessen pain) gait without any assistive device.  The spine examination revealed mild lower lumbar tenderness with no gross spine abnormalities or muscular spasms.  ROM measurements showed a flexion of 95 degrees, and a normal combined ROM 240 degrees.  There was “discomfort” at the extremes of ROM.  Strength, sensation, and DTRs were normal.  The impression listed degenerative changes in the lumbosacral spine with moderate functional impairment.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5295 code (lumbosacral strain), citing chronic low back pain secondary to degenerative disc disease, L5-S1 central disc bulge which does not impinge neural elements by imaging, no radiculopathy, and no spasm.  The VA assigned a 10% rating under the 5295 code (lumbosacral strain), citing low back pain, degenerative disc disease at L5-S1 with a central disc bulge without impingement of neuro elements by imaging, unremarkable lower extremities neurologic examination, no spasm, and rated for characteristic painful and slight limited motion.  

In accordance with DoDI 6040.44, the panel is required to recommend a rating IAW the VASRD in effect at the time of separation.  The panel noted that the 2002 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The panel must correlate the above clinical data with the 2002 rating schedule and applicable diagnostic codes.  There was no vertebral fracture (5285), complete spine ankylosis (5286), dorsal spine ankylosis (5288), lumbar spine ankylosis (5289), limitation of dorsal spine motion (5291), limitation of lumbar spine motion (5292), or sacro-iliac injury/weakness (5294) for consideration under the respective codes.  There was no neuropathy, characteristic pain, muscle spasm, absent DTR, neurological findings appropriate to disc site, or recurring attacks for consideration under intervertebral disc syndrome (5293).  

Panel members agreed a 10% rating was supported under lumbosacral strain (5295) based on characteristic pain on motion.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 low back condition.  

Contended PEB Conditions:  Left Knee Iliotibial Band Syndrome and Right Shoulder Anterior Dislocations.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended left knee and right shoulder conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were 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 20150712, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011057, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

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,