RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX		CASE: PD-2015-02287 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20060730

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

CI CONTENTION: The CI contends his back condition has gotten worse. 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 - 20060602		VARD - 20070413	
Condition	Code	Rating		Condition	Code	Rating	Exam	
Low Back Pain	5242	10%		DJD Lumbar Spine	5242	10%	STR	
COMBINED RATING: 10%		COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Low Back Pain. According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began in March 2005 after he caught a heavy weight. Radiographic studies performed in August 2005 showed bulging lumbar intervertebral discs with mild to moderate narrowing of the nerve passageways in the spine (neural foraminal narrowing).

The 10 May 2006 MEB NARSUM, 3 months prior to separation, noted complaints of constant low back pain rated 7-8/10 in severity, worsened by standing for more than 10 minutes, walking more than 2 blocks, repeated bending, or lifting more than 20 pounds. Physical examination showed gait assisted by a cane (this was due to separate ankle injury).  Tenderness was noted on the

lower spine. Range of motion (ROM) was recorded as flexion at 70 degrees (normal 90) and combined ROM at 190 (normal 240), with all planes of motion limited by pain. There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back pain 10%, coded 5242 (degenerative arthritis of the spine), citing tenderness and pain limited motion. The VA also rated the back condition at 10% with the same code (5242) based on the STR, citing ROM criteria. 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) and tenderness, as reported on the NARSUM. 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 (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS). 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 low back pain condition.

BOARD FINDINGS: In the matter of the low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication. There were no other conditions within the panel’s scope of review for consideration. The panel, therefore, recommends that 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 20150704, w/atchs Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

AR20170012174, 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,