RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01993
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060801

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

CI CONTENTION:  “Please consider all conditions listed.”  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 - 20060419	VARD - 20070612	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	0%	Chronic Mechanical Low Back Pain	5237	0%	20061002	
Migraine Headaches	Not Unfitting	Migraines, Residual Head Injury	8100	0%	20061002	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR), the CI’s back condition began in approximately 2003 and was unassociated with a specific injury.  An MRI study was normal.  A chiropractic examination on 21 October 2005, 9 months prior to separation, noted pain during lateral flexion, and lower back tenderness but no muscle spasm.  At the Medical Evaluation Board (MEB) examination (recorded on the DD Forms 2807 and 2808) on 23 February 2006, 5 months prior to separation, the CI reported chronic low back pain on a daily basis that interfered with sleep.  Pain severity was 3-8/10.  Physical examination showed the ability to “heel, toe and duck walk easily with some complaint of LBP.”  Grimacing was observed while getting on and off the examination table.  Diffuse lower back tenderness was present.  The CI reported pain with examination maneuvers not expected to elicit pain based on the known pathology.  Range of motion (ROM) testing was not performed.  Examination by physical therapy (PT) on 3 March 2006 showed thoracolumbar flexion of 90 degrees (normal 90) and combined ROM of 215 degrees.  Measurements were performed after 3 repetitions.  Pain was reported in all planes of motion.  At the narrative summary evaluation on 14 March 2006 the CI reported that her back pain was caused by a parachute jump in December 2003.

At the 2 October 2006 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported that her back pain traveled “into her tailbone area [and] into her upper buttocks.”  She denied spine-associated stiffness, weakness, incapacitation or functional impairment.  Pain severity was 7/10, but she had not taken pain medication for months.  She could vacuum, take out the trash, perform gardening activities and push a lawn mower.  She worked for a hardware store, and activities included sales and stocking.  Physical examination showed no muscle spasm or tenderness, and a normal gait and spinal curvature.  Thoracolumbar flexion was 90 degrees and combined ROM was 240 degrees.  Repetitive motion did not cause additional limitation.  There was no sign of intervertebral disc syndrome (IVDS).  The examiner concluded that there was no pathology to render a diagnosis.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded analogously to 5237 (lumbosacral strain).  The VA also rated the back condition 0% under the same code, based on the C&P examination 2 months after separation, on the basis of no limitation of motion.  The panel noted that the C&P examination was more proximal to the time of separation than the service PT examination, and did not reflect indicators of possibly unreliable findings.  The panel therefore assigned the C&P examination preponderant probative value in its deliberations.  That examination showed no limitation of thoracolumbar spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine, nor did it show painful motion, muscle spasm, guarding or localized tenderness.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height, and no evidence of additional functional loss that would impact functioning in the average civil occupation.  Finally, there was no documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  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.  

Contended PEB Condition:  Migraine Headaches.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition 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 the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended migraine condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  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 20150715, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010025, 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,