RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00011
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Combat Engineer, medically separated for “low back pain” with a disability rating of 10%.

CI CONTENTION:  Used evidence support a higher rating.  Current condition supports a higher rating.  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 – 20040708 	VARD – 20060613 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Thoracolumbar Spine Degenerative Disc Disease	5237	20%	20051228	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Mechanical Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back injury began in December 2002 while playing racquetball.  He was subsequently reinjured in 2003 during skiing at Cold Weather Leadership Course after he collided with another member.  Radiographic imagining (X-ray) studies in July 2003 and January 2004 were normal.  An MRI performed in February 2004 showed mild to moderate spondylosis L1-L2 level with no evidence of disc herniation or spinal stenosis.  There was no surgical indication and despite conservative treatment, the low back pain condition could not be adequately rehabilitated.

At a 19 April 2004 Primary Care clinic visit, 12 months prior to separation, the CI complained of chronic low back pain for over 1 year that was worse with sit-ups, moving heavy equipment and running.  Physical examination documented range of motion (ROM) as full flexion with painful motion (measurements were not cited).

The 19 May 2004 MEB NARSUM examination, 11 months prior to separation, noted complaints of significant pain and flares every 2 months, depending on physical activity.  Physical examination showed a spinal muscle spasm and tenderness with increased lordosis; gait as not addressed.  ROM was flexion to 75 degrees (normal 90) and combined ROM was 155 degrees (normal 240) with painful motion.

During a 15 February 2004 Primary Care visit, 2 months before separation, the CI presented for frost-bite ear injury 30 days earlier.  In addition, the CI reported back pain that shot up the back but not down the legs; with no known aggravation of pain.  He reported normal urine and bowel function.  The low back physical examination showed spinal tenderness and straight leg raise test for radiculopathy was normal.  ROM was not addressed.  The CI was diagnosed with chronic low back pain “determined by Med Board.”

At the 28 December 2005 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported intermittent low back pain without flare-ups.  Physical examination showed a normal gait without spinal tenderness, but spinal tenderness was present.  ROM was flexion to 45 degrees and combined ROM was 130 degrees with painful motion.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain), citing tenderness to palpation.  The VA rated the low back condition 20%, also coded 5237, based on the C&P examination 3 months after separation, citing for muscle spasm, pain, stiffness and weakness.

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) and combined ROM (greater than 120 degrees but not greater than 235 degrees) based on the preponderance of STR evidence.  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 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 that there was insufficient cause to recommend a change in the PEB adjudication for the low back pain condition.
BOARD FINDINGS:  In the matter of the chronic low back 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 20151231, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013181, 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