RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  PD-2015-02074
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061107

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Information Technologies Specialist, medically separated for “chronic low back pain (LBP),” with a disability rating of 0%.

CI CONTENTION:  “Lumbago and L3-L4/L4-L5 Lumbar disk degeneration.  Tendonitis Rotator Cuff.”  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 - 20060711	VARD - 20080619	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	0%	LBP	5237	NSC	20080319	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS: NSC	

ANALYSIS SUMMARY:  

Chronic Lower Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in December 2002 after lifting a heavy printer.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.  During the 23 May 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported experiencing LBP, particularly on the right side.  Examination revealed decreased range of motion (ROM) measurements (degrees not specified) with pain on motion.  On the same day, the MEB NARSUM examination took place revealing the CI complained of continued back pain, particularly on the right side, with increased pain with several activities; running, lifting, carrying, prolonged sitting and upon wakening in the morning.  Physical examination showed normal motor and sensory functioning, no tenderness to palpation, a negative Faber’s test (measures pathology of the hip and sacroiliac joint) and pain on motion.  ROM showed forward flexion 65 degrees (normal 90), extension 20 degrees (normal 30), right lateral bend 35 degrees (normal 30), and left and right lateral bend 30 degrees (normal 30).  

On 10 April 2006, computed tomography (CT) showed lumbar spondylosis and degenerative disc disease.  At a 27 June 2006 physical therapy appointment, the examiner recorded reactive spasm of the paraspinal muscles with no radicular signs present.  The examination was silent on any observed altered gait or abnormal spinal couture.  Full range of motion was noted.  There was no VA Compensation and Pension (C&P) evaluation proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 0%, coded 5237 (lumbosacral strain), citing a combined passive ROM equal to 200 degrees with pain achieved at the mechanical limits.  The VA did not service connect the LBP condition, coded 5237, based on the C&P examination 16 months after separation, citing pain alone, without any underlying disease or injury, is not a disability for VA compensation purposes.  

The panel agreed 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 NARSUM examinations.  It was noted that muscle spasm was present on the 27 June 2006 PT examination; however there was not an associated abnormal gait or abnormal spinal contour to support the next higher rating of 20% (i.e. for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis).  Similarly, the C&P examination identified a spinal kyphosis, but the examiner was silent on the presence of any muscle spasm to support a 20% rating.  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The panel therefore concluded that an additional disability 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 recommends a disability rating of 10% for the chronic LBP condition, coded 5237.  

BOARD FINDINGS:  In the matter of the chronic LBP condition, the panel unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150727, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009995, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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 also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure