RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02405
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090828

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E3, Trainee, medically separated for “chronic radiating back pain,” with a disability rating of 10%.  

CI CONTENTION:  “Review 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 - 20090811	VARD - 20100409	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating Back Pain…	5299-5237	10%	DDD w/ Herniated Disk at L4-5	5242	0%	20100126	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Radiating Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in June 2008 with no history of injury or trauma.  Radiographic studies in June 2009 documented degenerative changes with a herniated disc in the low back.  Surgery was not recommended.  

At 6 separate physical therapy (PT) visits in March, April, May, and July 2009, physical examination showed a normal gait and full range of motion (ROM) with pain.  During the 8 July 2009 MEB examination (recorded on DD Forms 2697, 2807 and 2808), 2 months prior to separation, the CI reported low back pain (LBP) that limited lifting, carrying, and prolonged standing.  Physical examination showed tenderness of the lower back with normal reflexes; painful motion was not addressed.  At the 14 July 2009 PT visit, 2 months prior to separation, the CI complained of central LBP radiating into the lower extremities.  Physical examination showed normal ROM for flexion (normal 90), extension (normal 30), and right & left lateral flexion (normal 30), though rotation was not recorded.  Two days later (16 July 2009) the MEB NARSUM examination recorded complaints of constant radiating LBP increased with bending, lifting, running and prolonged standing.  The CI denied fatigue, weakness, incoordination and lack of endurance.  Physical examination showed a normal gait with no tenderness or muscle spasm.  Strength, sensation, and reflex testing were normal.  

At the 26 January 2010 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported LBP with bending, sitting or standing more than 30 minutes, lifting weights greater than 10 – 15 pounds, walking more than a mile, or climbing more than 2 or 3 flights of stairs.  She denied episodes of incapacitation.  Physical examination showed forward flexion to 90 degrees (normal) and combined ROM at 215 degrees (normal 240) with no evidence of painful motion.  There was no further limitation due to repetitive movements or pain.  There was no tenderness, spasm, abnormal spinal contour, evidence of guarding, or abnormal gait.  Strength, sensation, and reflex testing were normal.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing pain with extension and functional loss during flares.  The VA rated the back condition 0% coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 4 months after separation.  The panel agreed that a 10% rating, but no higher, was justified for the presence of painful motion reported on the PT examination.  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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

PANEL FINDINGS:  In the matter of the back 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 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 20150914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012636, 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.

	A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,					      
						      					
Enclosure