RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02410
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Combat Documentation Production Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  The CI requested to be re-evaluated with her condition classified as “lumbar degenerative disc/joint disease.”  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 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 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 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 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 - 20040309	VARD for Vocational Rehabilitation - 20040513	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain Due to Degenerative Disc Disease	5299-5237	10%	Chronic Low Back Pain	5243	NA	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (Due to Lumbar Degenerative Disc Disease).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in early 2003.  The condition was aggravated in March 2003 after the CI fell down stairs.  Radiographic (x-rays) in April 2003 showed mild wedging of T12 and L1.  The examiner opined that this was most likely a result of “a congenital variant or prior trauma.”  An MRI done 10 September 2003 showed mild disc protrusion L4/5, with mild central canal stenosis, without neural foraminal involvement, and moderate L3/4 to L5-S1 degenerative facet arthropathy.  Electrodiagnostic studies were negative for radiculopathy.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The 4 December 2003 MEB NARSUM examination, 3 months prior to separation, noted complaints of persistent low back pain aggravated by prolonged walking, standing, sitting, marching, running, sit-ups, push-ups and lifting.  She was not able to lift objects greater than 20 lbs.  The examiner noted that her range of motion was a forward flexion of 60 degrees (normal 90), an extension of 20 degrees (normal 30), right lateral flexion of 20 degrees (normal 30), left lateral flexion of 30 degrees (normal 30), right rotation of 30 degrees (normal 30), and a left rotation of 30 degrees (normal 30).  She had pain limited motion, tenderness to palpation and her gait was “slightly antalgic, favoring the left lower extremity.”  EMG results were normal.  She had negative straight leg raising bilaterally, negative Faber test (assesses the sacroiliac joint) bilaterally, negative facet loading bilaterally, and she was able to heel/toe walk.  Her muscle strength was normal throughout and deep tendon reflexes (DTR’s) were +2 (normal) throughout, symmetrical.  The records available to the panel indicated that the CI did not attend a VA Compensation and Pension (C&P) evaluation.  The records did include a VA Rating Decision for vocational rehabilitation that was completed with MEB/PEB and military service treatment record (STR) information.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10%, coded analogously 5299-5237 (lumbar spine strain), citing pain limited motion and tenderness.  The VA did not rate the condition as she did not submit a claim.  The VA did grant vocational rehabilitation based on the CI’s MEB/PEB and STR information.  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) and/or combined ROM not greater than 120 degrees) reported on the NARSUM examination.  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).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve 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 LBP condition, analogously coded 5299-5237.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition, the panel unanimously recommends a disability rating of 20%, analogously coded 5299-5237 IAW VASRD §4.71a.  There are 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	
Chronic Low Back Pain	5299-5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150930, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012891, 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