RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02095
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040304

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Patriot Missile Crewmember, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.”  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 upon a 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 - 20040116	VARD - 20050713	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Lumbosacral Strain	5243	0%	20041202	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

Chronic Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began in 2000, without any specific history of injury or trauma.  On 8 July 2003, lumbar spine X-rays revealed no fracture, dislocation, spondylolisthesis, or spondylolysis.  The intervertebral disc spaces, vertebral height, and posterior neural arches were all within normal limits.  Magnetic resonance imaging (MRI) on 1 August 2003 showed L5-S1 degenerative disc disease (DDD) and disc bulge.  The CI was treated with physical therapy, nonsteroidal anti-inflammatory drugs, and activity modification.  In spite of all treatment efforts, the back condition did not improve adequately to meet the physical requirements of the CI’s military specialty.  The MEB forwarded “lumbago” for PEB adjudication.

The MEB NARSUM examination on 17 November 2003, 4 months before separation, noted complaints of low back pain without radicular symptoms (pain, numbness, tingling).  Physical examination showed a normal gait with spinal tender.  He was able to raise and sit without significant difficulty.  There was no sacroiliac joint pain and straight leg raise was negative.  Lower extremity strength was 5/5 (normal).  Range of motion (ROM) testing showed flexion 90 degrees (normal) and combined ROM of 240 (normal); painful motion was not addressed.

At the 02 December 2004 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported low back discomfort without radiating pain.  Physical examination showed normal posture, gait and reflexes.  He had a negative straight leg raise test and there was no muscle spasm or tenderness.  Thoracolumbar ROM showed flexion to 90 degrees and combined ROM of 240 degrees.  The examiner noted ROM was not limited by pain, weakness, fatigue or lack of endurance.

The Board directed attention to its rating recommendation based on the evidence.  The PEB rated the low back pain condition 10%, coded 5237 (lumbosacral strain), citing no significant loss of ROM, muscle spasm, or radiculopathy.  The VA rated the low back pain condition 0%, coded 5243 (intervertebral disc syndrome), based on the C&P examination 9 months after separation, citing a normal examination.

The Board agree there was insufficient limitation of motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine; however, the was sufficient evidence of spinal tenderness to support a 10%.  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.  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 Board found insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain.

BOARD FINDINGS:  In the matter of the unfitting 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 20150617, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170004080  , 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,