RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02226
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Construction Equipment Repairer, medically separated for “chronic low back pain,” with a disability rating of 10%.

CI CONTENTION:  “The injury required surgery.  Once separated from the military the injury was considered pre-existing so I have been unable to get the surgery.”  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 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 - 20040519	VARD – None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5239	10%	No VA Examination in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain condition began in October 2002 after a motor vehicle accident (MVA).  Radiographic (X-ray) studies showed a Grade-2 anterolisthesis of L4 on L5, with decreased disc space, and probable bilateral spondylolysis at L4.  Magnetic resonance imaging (MRI) studies showed a mild broad-based disc bulge at L2-3, L3-4, and at L4-5 there was spondylolysis.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “lumbar spine:  multilevel degenerative facet and disc disease, spondylolysis and spondylolisthesis” for PEB adjudication.  

At the time of the orthopedic clinic appointment on 6 August 2003, the CI reported low back pain, described as a combination of a chronic ache, stabbing pain, and pins and needles.  He rated the pain as 5/10 and denied radiation of pain.  Physical examination showed no evidence of scoliosis, no asymmetry, or atrophy.  There was normal muscle tone, strength, and reflexes.  Straight leg raise test was negative for radiculopathy.  There was normal range of motion (ROM) of the thoracic spine.  At flexion of the lumbar spine, the CI was able to bring his fingertips 20 inches from the floor (~45-60 degrees, normal 90), and extension of 15 degrees (normal 30).  There was pain at the extremes of motion.  The CI had a normal gait and was able to raise up on his toes and able to back on to his heels.  The MEB NARSUM examination on 17 September 2003 (10 months prior to separation) noted complaints of low back pain worse with when bending forward or in extension.  The CI stated that he had not found anything to make his pain better and that he was currently not using any medications.  Physical examination showed a normal gait, strength, reflexes and sensation.  There negative straight leg raise and Faber testing.  ROM measurements showed that the CI forward flexed approximately 16 inches from the floor (~65-80 degrees), extended 20 degrees and had good lateral bending and rotation.  Physical examination performed on 3 November 2003 was remarkable for tenderness to palpation over the lower lumbar spine with palpable spasm on the right.  Straight leg raise test was negative.  The MEB NARSUM examination on 21 April 2004 (2 months prior to separation) noted complaints of constant low back pain, aggravated by impact activities, repeated bending, and heavy lifting.   While walking at his own pace and distance, he felt random episodes of sharp low back pain that radiated down both legs, which caught him off guard and sometimes caused him to fall.  ROM was compiled and updated on 26 April 2004 and showed a forward flexion of 77 degrees with pain elicited at 67 degrees and a combined ROM of 215 (normal 240).  Neurological examination revealed normal reflexes and normal strength; however, decreased sensation in the outer calf of the right lower extremity and along the outer calf and foot of the left lower extremity, consistent with S1 nerve root sensory dysfunction was appreciated.  There was no VA Compensation and Pension (C&P) evaluation in evidence.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10%, coded 5239 (spondylolisthesis or segmental instability), citing some sensory dysfunction in the lower extremities but no radiculopathy, spasm noted on examination, and limited motion.  The Board 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 combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB NARSUM examination proximate to separation.  Although there was muscle spasm, it was not 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 (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), 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 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 chronic low back pain 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 20150602, w/attachments
Exhibit B.  Service Treatment Record

AR20170004217, XXXXXXXXXXXXXXXXXX. 

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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,					       
						      					
Enclosure