RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02373
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070322

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Cavalry Scout, medically separated for “low back pain [LBP]” with a disability rating of 0%.  

CI CONTENTION:  The CI contends that in addition to his low back injury, he also injured or aggravated his left elbow, left knee and left shoulder while on active duty.  The CI’s 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 - 20061206	VARD NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	0%	No VA Exam in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:  

Chronic LBP.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the low back condition began in November 2005 when the CI’s vehicle was sideswiped by a semi tractor-trailer.  Radiographic studies in November 2005  (X-rays) and May 2006 (MRI) revealed mild lumbar degenerative disc disease (DDD) without herniation or nerve impingement.  

At the 16 August 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 12 months prior to separation, the physical examination showed tenderness at the L2-L5 vertebrae and the paraspinous muscles.  Forward flexion in the seated position was decreased secondary to pain, with improved flexion while standing.  Bilateral lower extremity strength, sensation, and reflexes were normal.  There was no evidence of radiation with nerve tension testing.  At an 18 August 2006 Physical therapy (PT) visit, range of motion (ROM) measurements showed a forward flexion of 45 degrees (normal 90) limited by pain, with a total combined thoracolumbar ROM of 190 degrees (normal 240).  

At the 13 November 2006 MEB NARSUM examination, 9 months prior to separation, the physical examination showed tenderness in the bilateral paraspinous muscles from L2 to L5, with no bony tenderness or abnormalities.  The gait and toe walk were normal.  Bilateral lower extremity strength, sensation, and reflexes were normal.  There was no evidence of radiation with nerve tension testing.  There was no VA examination in evidence within the 12-month allowable window for adjudication.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5237 (lumbosacral strain), citing tenderness and ROM limited by pain.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the PT examination.  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 panel recommends a disability rating of 20% for the low back condition, coded 5237.  

BOARD FINDINGS:  In the matter of the back condition, the panel unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
LBP with DDD	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150918, w/atchs
Exhibit B.  Service Treatment Record

AR20170012619, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure