RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02194
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Fire Support Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  The CI contends that he had muscle spasms in his back that were not considered.  The CI’s 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 - 20030924	VARD - 20040226	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5293-5299
5295-8520	10%	Status Post Lumbar Spine Surgeries with Severe DDD	5243	20%	20031017	
			Left Lower Leg Radiculopathy	8520	20%	20031017	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50	

ANALYSIS SUMMARY:

Lumbosacral Strain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began in 1995 after a parachute jump.  The CI received an L5-S1 discectomy in December 1996, and an L5-S1 re-exploration and nerve root decompression in August 2001.  Radiographic studies showed mild diffuse lumbar spondylosis with degenerative disc disease (DDD) at L4-5 and L5-S1.  The MEB forwarded left S1 radicular symptoms, status post diskectomy; paresthesias in the distal S1 distribution on the left side, and low back pain secondary to diskectomy for PEB adjudication.

At the 25 October 2002 MEB NARSUM examination, 14 months before separation, the CI complained of back pain exacerbated by military duties.  On physical examination provocative maneuvers to elicit radicular pain were positive, but the CI had normal motor strength, reflexes, and sensation.  Range of motion (ROM) was not addressed.  At the 17 June 2003 MEB NARSUM examination, 7 months before separation, the CI had a normal gait and there was no spine tenderness or spasm.  Provocative maneuvers to elicit radicular pain were negative and the CI was noted to have normal motor strength and sensation.  ROM was not addressed.  At the 25 July 2003 physical therapy MEB ROM study, 5 months before separation, The CI reported 7/10 back and left leg pain.  The ROM examination showed flexion of 15 degrees (normal 90), but the examiner noted that the CI could flex to 100 degrees with passive ROM testing.  Combined thoracolumbar ROM was 100 degrees (normal 240).  There was no report of painful motion. 

The 25 August 2003 orthopedic examination, 4 months before separation, noted complaints of pain radiating down the left leg to the foot.  On examination left lower extremity motor strength was slightly decreased at 4+/5 and there was decreased sensation at L5-S1.  Forward flexion was noted to be “very minimal.”  The examiner did not list any other planes of motion. 

At the 17 October 2003 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, the physical examination showed normal gait, posture, motor strength, reflexes, and sensation.  ROM testing showed flexion of 65 degrees, and combined thoracolumbar ROM of 210 degrees.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, analogously coded 5293-5299 and 5295-8520 (intervertebral disc syndrome and lumbosacral strain - paralysis of muscles below the knee (sciatic nerve)).  The VA rated the low back condition 20%, coded 5243 (intervertebral disc syndrome) based on the C&P examination 3 months before separation, citing limited motion.  The VA also rated the left lower leg radiculopathy condition 20%, coded 8520, citing moderate incomplete paralysis of muscles below the knee.  In accordance with DoDI 6040.44, the panel is required to recommend a rating IAW the VASRD in effect at the time of separation, which is the 2004 VASRD standards for the spine (effective 26 September 2003).

The panel deliberated the probative value of the orthopedic, physical therapy and C&P examinations proximate to separation.  The respective physical therapy and orthopedic ROM findings of flexion at 15 degrees and” minimal,” corroborate a 40% rating; however, the panel determined these examination were not comprehensive, and the orthopedic flexion ROM was not quantified.  The panel agreed that the C&P examination had the highest probative value because it contained comprehensive findings and was most proximate to separation.

The panel agreed that 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, as reported on the VA examination proximate to separation.  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.  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 adjudication for the chronic low back pain condition.

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the Board 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 20150813, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010125, 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,