RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX
	CASE:  PD-2015-02202
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061009

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Human Intelligence Collector, medically separated for “chronic mechanical low back pain (LBP)” with a disability rating of 10%.

CI CONTENTION:  The condition continues to worsen and negatively impact daily activities.  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 - 20060707	VARD - 20070108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical LBP	5299-5237	10%	Degenerative Disc Disease of the Lumbar Spine with Intervertebral Disc Disease Syndrome	5242	20%	20060816	
			Radiculopathy to the Right Lower Extremity	8699-8620	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Mechanical LBP.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic mechanical LBP condition began in September 2003 after experiencing gradual onset of back pain without specific injury or trauma.  

The 23 October 2003 computerized tomography (CT scan) of the lumbar spine showed broad-based disc bulges at both L4-5 and L5-S1 with no significant central canal or neuroforamenal stenosis.  At the 7 September 2005 Physical Medicine and Rehabilitation (PM&R) clinic appointment, 13 months prior to separation, the CI complained of frequent, sharp and severe bilateral LBP that radiated down the right posterior upper leg intermittently.  Physical examination showed a normal gait.  ROM was recorded as extension 75 percent of normal with painful motion and bilateral flexion 25 percent of normal.  The note references a lumbosacral spine magnetic resonance imaging (MRI) scan from 29 August 2005 that was not available for review, but was noted as “normal” per the examiner.  The PM&R physician opined that in light of the MRI findings her pain was most likely soft tissue injury.  

At the time of 31 March 2006 primary care clinic appointment, 7 months prior to separation, the CI reported constant back pain that was worse and radiated to her right leg when wearing body armor.  On examination, the CI exhibited full forward flexion; however, ROM measurements were not provided.  Tenderness was noted throughout the lumbosacral spine.  

The 20 April 2006 MEB NARSUM examination, 5 months prior to separation, noted complaints of constant LBP.  She stated that she was unable to run at any pace and unable to perform any of the parts of the physical fitness test.  On examination, there was a normal gait and no muscle spasms.  The ROM showed forward flexion of 110 degrees (normal 90) with a combined ROM of 235 degrees (normal 240) with painful motion on some movements.  

At the 16 August 2006 VA Compensation and Pension (C&P) evaluation, 2 months prior to separation, the CI reported constant LBP that traveled down the right leg.  The back pain did not cause incapacitation.  The condition was exacerbated with prolonged sitting, running, jumping and lifting greater than 20 pounds.  Physical examination showed a normal gait and posture, no muscle spasms and no ankylosis of the lumbar spine (abnormal stiffening or immobility).  The CI exhibited tenderness.  The ROM was recorded as flexion to 55 degrees (normal 90) and a combined ROM of 125 degrees (normal 240).  Painful motion was noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic mechanical LBP condition 10%, coded 5299-5237 (analogous to lumbosacral strain), citing a combined ROM of greater than 240 degrees with localized tenderness.  The VA rated the low back condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 2 months before separation, citing forward flexion limited to 55 degrees.  

Panel members considered the ROM measurements in the C&P evaluation and noted that the reported ROM measurements were at the point where pain began and that the complete ROMs were not reported.  As such, the panel discounted this single evaluation in making its rating recommendation.  The panel agreed that a 10% rating, but no higher, was justified for a combined ROM of greater than 120 degrees, but not greater than 235 degrees; or localized tenderness not resulting in abnormal gait.  There was no limitation of motion that justified a 20% rating.  Additionally, 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 evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic mechanical LBP condition.  

BOARD FINDINGS:  In the matter of the chronic mechanical LBP 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 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 20150806, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010611, 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,