RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01991
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080325

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Cannon Crewmember, medically separated for “low back pain” with a disability rating of 10%.

CI CONTENTION:  The CI contends that his rating should be changed because his post-surgical back is still symptomatic and prevents him from lifting heavy loads.  The CI’s 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 - 20080307	VARD - 20080823	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5237	10%	Lumbar Disc Herniation, L4-5	5243	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery with discectomy in March 2007 for herniated disc at L4-5.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty and his neurosurgeon stated that he wasn’t a candidate for further surgery.  During the 3 December 2007, MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported low back pain with no improvement after surgery.  He was “unable to lift anything.”  Physical examination showed decreased flexion and extension, but the examiner did not provide actual range of motion (ROM) measurements.  The CI had normal gait, motor strength and reflexes. The 15 January 2008, MEB NARSUM examination, 2 months prior to separation, noted complaints of back pain at the 8 out of 10 level with “high impact activities such as running, jumping climbing, lifting, pushing, pulling or marching over rough and irregular terrain.”  Prolonged sitting or standing also caused his back pain to intensify.  The CI described muscle spasm at times when engaged in ordinary activities.   Physical examination showed tenderness.  The examiner noted that the CI was “able to bend forward with hesitancy to remove and replace his shoes” and that any limitation of motion was because of pain and not mechanical causes, however the examiner provided no ROM measurements.  The CI had normal gait, spinal contour, motor strength, sensation, and reflexes.  There was no spasm present.  Thoracolumbar range of motion (ROM) measurements performed by physical therapy (PT) on 15 January 2008, 2 months prior to separation, showed, after repetition, flexion of 70 degrees (normal 90), with pain, and combined ROM of 200 degrees (normal 240).  The examiner noted decreased motor strength in the right knee (4/5) and right hip (4+/5), but the CI was noted to have a non-antalgic gait with normal reflexes, and sensation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5237 (analogous to lumbosacral strain), citing limitation of motion.  The VA rated the back condition 0% coded 5243 (intervertebral disc syndrome), citing “incapacitating episodes having a total duration of less than one week during the past 12 months” and “forward flexion of the thoracolumbar spine of greater than 85 degrees; or, combined ROM of the thoracolumbar spine greater than 235 degrees.”  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees and/or combined ROM greater than 120 degrees but not greater than 235 degrees reported on the PT ROM study.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  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 back condition.  

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150715, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010023, 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,