RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02222
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030618

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Electronic Warfare Intercept System Repairer, medically separated for “low back pain,” with a disability rating of 10%.  

CI CONTENTION:  The CI requests the Board consider all conditions.  His 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 - 20030404	VARD – 20040114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain, No Neurologic Impairment	5295	10%	Muscular Low Back Strain	5299-5292	10%	20021209	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Low Back Pain, No Neurologic Impairment.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began in November 1998 after participating in an 18.6 mile ruck march.  Radiographic evaluations (X-ray, bone scan, and MRI) of the back in 2002 were normal.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “mechanical low back pain” for PEB adjudication.  

At the 9 December 2002 VA Compensation and Pension (C&P) evaluation, performed 6 months before separation, the CI reported he was having a significant flare of pain, nearly incapacitating for one week twice a year.  He had moderate pain continually that was aggravated by military required activities of running, sit-ups, push-ups and wearing ruck sacks and lifting activities.  
Physical examination revealed range of motion (ROM) measurements with forward flexion of 70 degrees (normal 90), waist twisting to 25 degrees bilaterally (30 normal) and lateral tilting to 30 degrees bilaterally (normal).  Tilting motion caused pain.  He had a natural lordosis and was tender from L4 to his sacrum.  Straight leg raise to 90 degrees bilaterally was without discomfort.  

The MEB NARSUM examination on 24 February 2003, 4 months prior to separation, noted complaints of low back pain with rare shooting pain down the left leg pain with twisting of his back.  The CI reported the sharp shooting pain caused his left leg to give out.  Pain was rated at 7/10 increasing to 9/10 with carrying, lifting, running, exercises or any strenuous physical activity.  Physical examination repeated previous ROM measurements with forward flexion of 70 degrees, twisting to 25 degrees bilaterally and laterally tilting to 30 degrees bilaterally now with painful motion.  Tenderness to palpation was present, right greater than left.  Straight leg raise to 90 degrees bilaterally was without discomfort.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5295 (lumbosacral strain), citing pain on motion.  The VA rated the low back condition 10% coded 5299-5292 (lumbar spine limited by motion), based on the VA C&P examination 6 months before separation, citing slightly limited motion of the lumbar spine or demonstrable deformity of a vertebral body from fracture with slight limitation of motion.  Board members agreed that the evidence did not support a 20% rating for moderate lumbar limitation of motion or muscle spasm on extreme forward bending.  There was no evidence of spinal fracture with limitation of motion or muscle spasm for an addition 10% for demonstrable deformity of the vertebral body.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

BOARD FINDINGS:  In the matter of the 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 20150817, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160018776 (PD201502222)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA