RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02025
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060404

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Fire Support Specialist, medically separated for “chronic low back pain,” with a disability rating of 0%.

CI CONTENTION:  The CI contends that his condition should have received a 40% disability rating.  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 - 20060117	VARD - 20061023	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	0%	Lumbar Strain	5237	0%	20060725	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in July 2004 after a fall during basic training.  Radiographic (X-ray) studies showed narrowing L4/5 disc space consistent with degenerative disc disease.  Magnetic resonance imaging (MRI) studies on 23 February 2005 showed degenerative disc disease at L4, L5 with midline protrusion and annulus tear with moderate to marked narrowing of the thecal sac.  There was no surgical indication.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “chronic low back pain” for PEB adjudication.
During the MEB examination (recorded on DD Forms 2807 and 2808) dated 15 September 2005, 7 months prior to separation, the CI reported recurrent back pain.  Physical examination showed a normal spine.  The MEB NARSUM examination on 17 November 2005 (4 months prior to separation) showed range of motion (ROM) with a normal flexion of 90 degrees and a normal combined ROM of 240 degrees.  Physical therapy range of motion (ROM) measurements by goniometer, dated 21 November 2005, noted full combined ROM. 

At the 25 July 2006 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported complaints of stiffness and pain in the lower back.  The pain occurred once per week and lasted about half an hour and did not travel.  There was no incapacitation, bed rest, numbness or tingling in the extremities, and functional impairment was denied.  Physical examination showed a normal gait and posture, no muscle spasm or tenderness, and no pain during ROM measurements.  ROM measurements showed a normal flexion and combined ROM, and after repetitive use there was no pain, fatigue, weakness, lack of endurance or incoordination.  

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated the back condition 0%, coded 5237 (lumbosacral strain), citing normal ROM not limited by pain.  There was no limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine and the MEB and VA C&P examinations did not note the presence of 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, nor was there evidence of additional functional loss that would impact functioning.  The Board concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board 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 low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, 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 20150722, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170004072, 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. 

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX.
Sincerely,