RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02133
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041020

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Motor Transport Operator, medically separated for “chronic low back pain [LBP]” with a disability rating of 0%.

CI CONTENTION:  The CI’s condition continues to worsen and negatively impacts daily activities.  The 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 - 20040802	NO VA CLAIM	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LBP	5237	0%	--	--	--	--	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  There was a paucity of source clinical notes in the available service treatment record (STR) for this case, and the Board’s recommendation was derived primarily from the Medical Evaluation Board (MEB) narrative summary (NARSUM) and core military Disability Evaluation System documents.  The CI developed an onset of back pain in May 2003 after a motor vehicle accident.  Pain persisted, but there was no report of radicular symptoms, and diagnostic imaging (MRI) was normal (incidental finding of benign congenital cysts [Tarlov]).  There was no STR evidence for significant range of motion (ROM) limitation, abnormal gait, abnormal spinal contour (other than an incidental X-ray finding not correlated with guarding or spasm), abnormal neurological findings, or periods of incapacitation.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for an MEB which in turn forwarded “chronic LBP” to the PEB.
The NARSUM examination (corroborated by the MEB’s DD Form 2808, Report of Medical Examination) on 7 July 2004 (3 months before separation) documented back pain unresponsive to treatment without mention of radiation or neurological symptoms, and listed only profile restrictions as functional limitations.  The physical examination recorded the absence of tenderness or spinal deformity and normal neurologic findings (motor, sensory, and reflexes).  No formal ROM measurements were located in the available STR, but the NARSUM stated that ROM was “somewhat limited by discomfort but not by any anatomic pathology.”  There was no VA claim, examination, or clinical notes on file; and, there was no other post-separation evidence in this case.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating under code 5237 (lumbosacral strain) cited “limitation of spinal motion due to pain only,” consistent with application of Army Regulation 635-40 (B-29, e).  Members agreed the NARSUM evidence was sufficient to support application of VASRD §4.59 (painful motion) in defense of the minimum compensable rating (10%).  Although the ROM evidence in this case was scant and a definitive assessment was not possible, members agreed there was no support for a rating higher than 10% based on ROM criteria. There was no evidence for abnormal gait or spinal contour to support a 20% rating, no evidence for ratable peripheral nerve impairment that would provide for additional rating, and no documentation of incapacitating episodes or diagnosis of intervertebral disc syndrome that would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the lumbar condition under code 5237.  

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

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

CONDITION	VASRD CODE	PERMANENT RATING	
Myofascial Pain, Lumbar Spine	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150616, w/atchs
Exhibit B.  Service Treatment Record

AR20170004208, XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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,