RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02574
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Missile Systems Repairer, medically separated for “back pain” with a disability rating of 0%.  

CI CONTENTION:  “Chronic back pain.”  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 - 20040219	VARD - 20040722	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain…Removal of Pilonidal Cyst	5299-5237	0%	Back Pain Post Removal of Pilonidal Cyst	5299-5237	10%	20040505	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain condition began in July 2001 after receiving spinal anesthesia for a surgical procedure.  Radiographic studies were within normal limits.  Follow-on imaging studies (MRI & CT) only revealed a hemangioma at L5.  

The 30 July 2003 MEB NARSUM examination, 11 months prior to separation, noted complaints of non-radiating mid-line back pain.  The physical examination revealed noticeable grimacing from the CI with movement.  There was some tenderness at the mid-line of his back.  The CI also had a normal gait.  There were no range of motion (ROM) measurements recorded.  

At the 5 May 2004 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported significant low back pain with bending, flexing and prolonged sitting. The physical exam showed a 65 degrees of flexion (normal 90) and combined ROM was 185 degrees (normal 240).  The examiner further noted the presence of lordosis (which is the normal shape of the curve of the lumbar spine), the absence of muscle spasms, no tenderness to palpation (TTP) and decreased ROM due to pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain condition 0%, coded 5299-5237 (analogous to lumbosacral strain), citing TTP.  The VA rated the back condition 10% coded 5299-5237, based on the VA C&P examination 2 months before separation, citing greater than 60 degrees of forward flexion but not greater than 85 degrees on forward flexion.  

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 VA examination proximate to separation.  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 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).  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the back pain condition, analogously coded 5299-5237.  

BOARD FINDINGS:  In the matter of the back pain condition, the panel unanimously recommends a disability rating of 10%, 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	
Back Pain…	5299-5237	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151206, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013329, 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