RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02314
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “chronic low back pain (LBP),” with a disability rating of 10%.  

CI CONTENTION:  The CI contended for his back pain, sciatic pain, left side radiculopathy and PTSD.  Additionally, he contended for knee and finger conditions not identified by the MEB or PEB.  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 - 20061024	VARD - 20070706	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Lumbar Strain with L5-S1 Disc Protrusion	5237	10%	20070228	
			Lower Back Shrapnel Wound/Scar	7804	10%	20070228	
Anxiety Disorder	Not Unfitting	PTSD	9411	30%	20070414	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in April 2004 after a roadside attack while deployed.  The CI was hit with shrapnel from a close proximity grenade blast that rendered him unconscious.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “lumbar disk herniation at L5-S1” for PEB adjudication.  
At the time of the physical therapy clinic appointment on 31 October 2005, 14 months prior to separation, the CI reported recurrent low back pain (LBP) with occasional mid back pain.  On examination the CI exhibited tenderness to palpation and full range of motion (ROM) without pain.  At the time of the primary care clinic appointment on 14 December 2005, the CI reported constant pain radiating through his back with occasional exacerbations.  Physical examination revealed tenderness to palpation with full ROM and visual signs of grimacing during movements.  Magnetic resonance imaging (MRI) studies, on 5 January 2006, showed a disc protrusion at L5-S1.  Follow on X-rays, on 14 June 2006, showed a stable lumbar series without abnormality.  

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 10 July 2006, 5 months prior to separation, the CI reported recurrent back pain with occasional numbness and tingling in the legs.  Physical examination showed tenderness to palpation, decreased ROM (degree measurement not given), and normal lower extremity strength and reflexes.  Heel toe walk was normal.  Provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative.  

The MEB NARSUM examination on 14 August 2006, 4 months prior to separation, noted complaints of continued back pain and decreased sensation of the bilateral lower extremities, as conveyed on the DD Forms 2807 and 2808.  The orthopedic consult from 26 July 2006 was summarized and indicated no sensory deficits on examination.  Physical examination repeated the DD Form 2807 and 2808 results and ROM measurements of forward flexion to 90 degrees (normal 90) and a combined ROM of 230 degrees (normal 240).  There was a healed 1-cm x 2-cm scar over the lower back with minimal tenderness around the scar.  

At the 28 February 2008 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported constant low back pain that did not cause incapacitation.  Physical examination showed a normal posture and gait and no muscle spasms or radicular pain.  The CI’s back pain did not radiate on movement.  There was tenderness and painful motion with forward flexion of 90 degrees and a combined ROM of 240 degrees (normal).  Motor, reflex, and sensory functions were normal without evidence of intervertebral disc syndrome.  The CI had a depressed and hypopigmented scar (less than 6 square inches) on the right lower back that was tender.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic LBP condition 10%, coded 5237 (lumbosacral strain), citing a blast and shrapnel wound with a well healed scar, but persistent back pain and a disc protrusion with examination of normal ROM, motor and sensory findings; “rated for tenderness.”  The VA also rated the low back condition 10% coded 5237, based on the VA C&P examination 2 months after separation, citing painful motion.  The VA additionally rated the right lower back tender scar at 10% coded 7804 (scars, superficial, painful on examination), citing tenderness based on the same examination.  

Although not all examinations documented sufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of tenderness on all examinations and painful motion on multiple examinations.  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 (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  The Board adjudged that there was insufficient evidence that the tender lower back scar was additionally unfitting, and concluded that an additional disability rating was not justified on this basis.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  Radiographic studies supported some level of radicular nerve irritation or involvement, but physical examinations (physical medicine, PT, MEB NARSUM, and VA C&P) proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an additional disability rating was not justified on this basis.  

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 LBP condition.  

Contended PEB Conditions:  Anxiety Disorder, NOS.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  The psychiatry MEB consultation on 1 August 2006 diagnosed “anxiety disorder, NOS, largely in remission,” assessed no impairment for further military duty, and “very mild” impairment for social and vocational adaptability.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder, NOS, condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20150625, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170004242, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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