RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02503
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060718

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

CI CONTENTION:  “Review all conditions.”  The 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 - 20060404	VARD - 20070607	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5237	10%	Low Back Myofascial Pain and Sacroilitis	5299-5237	NSC	20070430	
Depressive Disorder NOS (in remission)	Not Unfitting 	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began insidiously in 1999.  She left active duty and re-enlisted in October 2003 at which time she reportedly experienced occasional back pain.  In February 2004, the CI reported right lower extremity pain in the right lateral foot.  An MRI was completed on 9 February 2006 which showed a broad based disc bulge at L4-5 with a small annular tear.  There was no significant spinal canal stenosis or neuroforaminal narrowing.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated August 2005, 11 months prior to separation noted tenderness to palpation of the right SI joint region.  Thoracolumbar range of motion (ROM) measurements performed by physical therapy (PT) on 25 October 2005 showed flexion of 90 degrees (normal 90) and combined ROM of 240 degrees (normal 240) with pain after repetition.  At the neurosurgery appointment of 10 February 2006, the CI reported constant low back pain with numbness in both feet, predominantly the right foot.  On examination there was painful lumbosacral motion (worse with flexion).  There was no tenderness to palpation or muscle spasms.  Sensation, motor and reflexes were all normal.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “lumbar spondylosis” and “chronic low back pain” for PEB adjudication.  The MEB NARSUM examination on 7 March 2006, 4 months prior to separation, noted complaints of back pain with right foot numbness.  The CI reported her back pain “improved somewhat” and the numbness was 50% improved after she was profiled for no APFT.  The provider referred to the DD 2807, the 2808 and the two PT examinations listed above.  

At the 30 April 2007 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported right sided low back pain that increases with heavy lifting of extended walking.  The CI stated her right foot gets a little numb when she uses the elliptical machine, but otherwise did not have any numbness, weakness or tingling.  She was working as a veterinary technician.  Incapacitating episodes were denied.  Physical examination showed full ROM.  There was no loss in ROM with repetition, but repetitive motion did cause pain.  There was no tenderness to palpation directly on the spine, but there was mild tenderness at the SI joint.  Gait and strength were normal.  The right foot had mildly decreased sensation to pinprick and the foot drifted into valgus during her gait.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5237 (lumbosacral strain), citing full painful range of motion, no tenderness and no spasms.  The VA did not service-connect the back condition based on the VA C&P examination 9 months after separation, citing full ROM with no objective evidence of painful motion and no evidence of an associated disability.  Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of painful motion and tenderness.  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 (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 Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

Contended PEB Conditions:  Depressive Disorder NOS.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended depressive disorder condition was not unfitting.  The contended condition was profiled an S2 and the MEB stated this condition met retention standards.  The 30 December 2005 psychiatric MEB addendum stated this condition was stable and her prognosis was favorable to return to full duty.  Her symptoms were well controlled with medication, coinciding with a more harmonious marriage and change in jobs.  GAF was 70.  The condition was stated to be in remission.  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 low back condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the contended depressive disorder condition, the Board recommends no change from the PEB determination of 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 20151025, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005410, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	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,