RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02068
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090314

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

CI CONTENTION:  The CI makes no contentions.  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 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 - 20081126	VARD - 20130731	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Low Back Condition	5237	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

Lumbosacral Strain.  According to the service treatment record (STR) and the Medical Evaluation panel (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in August 2006 after loading pallets on to a truck and again after falling down stairs in June 2007.   Diagnostic imagining revealed multi-level disc bulging of the lumbosacral spine.  He was not a surgical candidate and despite restrictions, medications, physical therapy and local injections, his condition did not sufficiently improve to allow unrestricted duty. 

The 15 October 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic low back pain aggravated with activity.  His physical examination (PE) revealed normal range of motion (ROM) of the thoracolumbar spine in all directions except a 2 degree loss in extension (28 vs 30 degrees).  Painful motion was present.  Gait, spinal contour, muscle spasm, guarding or tenderness were not addressed. 

A VA primary care visit on 23 April 2009, 1 month after separation, revealed intermittent low back and neck pain.  No radiating pain, numbness, weakness, headaches and no injury.  His PE revealed low back and neck tenderness.  Spinal ROM was not addressed.  There was no additional VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition at 10%, coded 5237 (lumbosacral strain), citing painful motion.  
The VA determined the low back condition was not service-connected.  The panel agreed that there was no STR evidence of limitation of thoracolumbar spine motion, muscle spasm, or guarding proximate to separation to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine.  The presence of tenderness as well as painful motion with functional loss did support a 10% rating (based on §4.59, §4.40 and §4.45) as documented by the MEB NARSUM and reflected in the PEB’s 10% rating.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula or evidence of ratable peripheral nerve impairment which would provide for additional rating.  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’s adjudication for the lumbosacral strain condition.  

BOARD FINDINGS:  In the matter of the lumbosacral strain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are 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 20150610, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009989, 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,