RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00055
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050813

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Signals Intelligence Analyst, medically separated for “chronic back pain” rated 10%.

CI CONTENTION:  The CI contends her unfitting condition continues to negatively affect her life.  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 - 20050617	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain ...  	5299-5237	10%	No VA Exam in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered an atraumatic onset of persistent low back pain in October 2003.  Imaging (MRI correlated with X-ray and bone scan) demonstrated a partial congenital fusion of L3 and L4 without degenerative changes or disc protrusion.  There was no STR documentation of any radicular pain or neurological complaints.  There was no STR documentation of any abnormal neurological findings.  There was no evidence probative to range of motion (ROM) in STR clinical entries.  There was no STR documentation of gait or spinal contour abnormalities, or of any incapacitating episodes.  

The 23 May 2005 NARSUM examination, 3 months before separation, documented persistent pain rated 6/10 (specifying the absence of radicular complaints) that was aggravated by prolonged sitting or standing and load bearing.  The physical examination recorded tenderness (no comment regarding gait, contour, or spasm) and normal neurological findings (5/5 strength, intact sensation, symmetric reflexes).  Normal neurological findings were corroborated by the MEB’s DD Form 2808 physical examination.  The NARSUM cited goniometric ROM measurements by physical therapy (PT): flexion to 60 degrees (normal 90) with a combined ROM of 175 degrees (normal 240).

There was no VA claim, examination, or clinical notes on file; and, there was no other post-separation evidence in this case.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5299-5237 (analogous to lumbosacral strain) acknowledged the absence of neurological abnormality, but otherwise cited only an erroneously calculated (counting measurements higher than VASRD normals) combined ROM of 200 degrees. The only ROM evidence in this case that was compliant with VASRD §4.46 (accurate measurement) was the PT evaluation from above.  The documented flexion to 60 degrees meets the VASRD §4.71a spine formula threshold for a 20% rating.  There was no evidence supporting a rating higher than 20%, no evidence of additionally ratable peripheral nerve impairment, and no documentation of incapacitating episodes or diagnosis of intervertebral disc syndrome that 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 recommends a 20% rating for the lumbar spine condition under code 5237.

BOARD FINDINGS:  In the matter of the lumbar spine condition, the panel unanimously recommends a disability rating of 20%, coded 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 her prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Back Pain with Congenital Spine Disease	5237	20% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160122, w/atchs
Exhibit B.  Service Treatment Record

AR20170013211, 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