RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXXXX	CASE: PD-2015-02288
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20061224

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

CI CONTENTION: The CI contends he should have received a medical retirement.  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 - 20060908		VARD - 20070409	
Condition	Code	Rating		Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%		Lumbar Spine Degenerative Disc Disease	5242	10%	20061201	
COMBINED RATING: 10%		COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Chronic Low Back Pain (LBP). According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic LBP condition began in November 2004 after tripping in a large hole and “snapping” his back during a training run. In March 2005, the CI fell from his truck following a convoy attack while deployed and re-injured his back.  In April 2005, the CI again re-injured his back during a physical fitness test.  At a 24 March 2006 neurosurgery clinic appointment, the CI reported experiencing progressively worsening back pain, particularly when wearing heavy field gear. Physical examination revealed tenderness to palpation (TTP) of the lumbosacral spine and a normal gait.  Radiographic studies

on 19 June 2006 showed a normal lumbar spine series. An MRI of the lumbar spine on 7 July 2007 showed mild disc space narrowing of L3-L4 and L5-S1 and mild degenerative disc disease, but no herniated discs and no significant spinal canal stenosis impinging nerves.

The 12 July 2006 MEB NARSUM examination, 5 months prior to separation, noted complaints of constant low back pain with exacerbations that sometimes rendered the CI unable to put on his own boots and caused sleep problems. Sitting and standing for long periods, running, sit-ups, push-ups, cold weather and intercourse increased the CI’s pain level. Physical examination showed the CI experienced pain during range of motion (ROM) testing and TTP. The ROM measurements showed forward flexion of 90 degrees (normal) and combined ROM of 195 degrees (normal 240). Of note, the examiner measured the lumbar ROM with an inclinometer rather than a goniometer specified by the VASRD (§4.71a, Plate V). At the 1 December 2006 VA Compensation and Pension (C&P) evaluation, performed a month before separation, the CI reported ongoing back pain. On examination, the CI had a normal posture and gait without tenderness. ROM measurements were not performed at the C&P evaluation.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing tenderness, pain with motion and a combined passive ROM of 210 degrees. The VA rated the low back condition 10% coded 5242 (degenerative arthritis of the spine), based on the C&P examination 1 month before separation and ROM measurements in the STR, citing pain on motion. The panel agreed that a rating of 10%, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM examination. There was no muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour to justify a higher 20% rating. There was also 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 back condition.

BOARD FINDINGS: In the matter of the back 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 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 20150825, w/atchs Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

AR20170012176, 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