RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02584
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020625

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

CI CONTENTION:  His condition continues to worsen and negatively impact daily activities.  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 - 20020415	VARD - 20020927	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical Low Back Pain…	5299-5295	10%	Mechanical Low Back Pain	5010-5292	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Mechanical Low Back Pain (LBP).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in November 1999 after heavy lifting.  At times the pain shot down to the right leg.  It was aggravated on 17 September 2001 when he was involved in a car accident.  X-rays were unremarkable but orthopedics was consulted.  Neuroimaging showed no disc disease or stenosis.  Conservative measures were not helpful and the pain persisted.  The pain was constant and slight.  

The 14 March 2002 MEB NARSUM examination, 3 months prior to separation, noted complaints of low back pain.  He was assigned to the motor pool and was mostly sitting around the office with no strenuous activities.  He took an over the counter medication for pain.  Physical examination showed tenderness.  Straight leg raise testing was negative and he could heel and toe walk without difficulty.  Motor and sensory examination of the lower extremities was normal.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, analogously coded as 5295 (lumbosacral strain).  The VA also rated the back condition 10% dual coded as 5010-5292 (arthritis due to trauma and limitation of motion of the lumbar spine), based on the STR, citing slight limitation of motion.  The panel agreed that criteria supporting a rating higher than 10% under the 5295 code are not in evidence (i.e. “with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position”); but debated if a higher rating is supported under other codes in effect at the time of separation.  Under the 5292 code a 20% rating is justified for “moderate” limitation of lumbar motion, but based on the evidence at hand panel members concluded that this degree of limitation was not present.  Likewise, there was no evidence of incapacitating episodes to warrant a minimal rating under the 5293 code.  

The panel finally considered if additional disability was justified for peripheral nerve impairment.  Although there were inconsistent complaints of radiating pain to the right leg, MRI showed no nerve root compromise; and there was no motor impairment that could be linked to any functional deficit or limitation of specific physical requirements.  The panel therefore concludes that additional disability rating for radiculopathy was not justified.  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 chronic mechanical LBP condition.  

BOARD FINDINGS:  In the matter of the chronic mechanical LBP 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 20150801, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013336, 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