RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02404
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051217

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

CI CONTENTION:  The CI requested a review of all conditions.  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 - 20051014	VARD - 20060426	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	10%	Status Post Low Back Injury	5237	10%	20060131	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in April 2003 without any specific injury or trauma.  X-rays taken on 21 October 2003 showed bilateral PARS defects (stress fracture) at L5 without evidence of degenerative changes.  A computed tomography (CT) of the lumbar spine on 12 November 2003 showed bilateral L5 spondylosis.  His condition was aggravated during his deployment in 2004-2005 and when he returned his March 2005 X-rays showed L5-S1 degenerative changes.  An magnetic resonance imaging (MRI) on 29 April 2005 showed L5 spondylosis without disc herniation, stenosis, or narrowing at any level.  

At the 15 July 2005 physical therapy (PT) clinic appointment, the CI reported 6 out of 10 back pain on a pain scale of 10.  His active range of motion (ROM) was within normal limits, but the CI complained of increased pain with flexion and extension movements.  There was tenderness to palpation at L4-L5.  His motor strength was normal and tests for radiculopathy were negative.    
 
During the MEB examination (recorded on the MEB NARSUM and DD Forms 2807 and 2808) dated 1 August 2005, 5 months prior to separation, the CI reported that his back pain after his morning stretching routine was 6-7 out of 10 on the pain scale.  He also reported that his back pain was aggravated by bending, twisting, prolonged standing, and walking.  On examination he was noted to have “slight limitation of movement with associated pain.”  However, no ROM measurements were taken.  The examiner noted tenderness, but no spasm.  He had a normal gait, motor strength, sensation, and reflexes and tests for radiculopathy were negative.  Thoracolumbar range of motion (ROM) measurements performed by physical therapy (PT) on 23 August 2005 (4 months prior to separation) showed flexion of 80 degrees (normal 90) and combined ROM of 230 degrees (normal 240) after repetition.  There was no evidence of painful motion.

At the 31 January 2006 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported that his back pain “radiated to his neck and to his buttocks and to his knees.”  He also reported that it limited his ability to bend and exercise.  Physical examination showed flexion of 90 degrees (normal 90) and combined ROM of 240 degrees (normal 240) after repetition with painful motion.  The examiner noted “because of the pain I feel we should allocate him at least a 10-degree loss in forward flexion and extension.”   The CI had paraspinal tenderness and spasm, but his gait was normal and “there were no obvious deformities” of his spine.  Straight leg raise testing for radiculopathy was positive on the left side at 45 degrees, but he had normal motor strength, sensation, and reflexes of the lower extremities. 

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 “passive ranges of motion equal 230 degrees including 80 degrees of flexion.”    The VA also rated the back condition 10% coded 5237, based on the VA C&P examination 2 months after separation, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees.  

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 reported on the physical therapy and VA examinations.  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 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 20150926, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170012634, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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