RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00085
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090921

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for “chronic thoracolumbar spinal pain,” rated 10%.  

CI CONTENTION:  The CI requests evaluation and review rating using the VASRD, according to the Wounded Warrior Act.  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 - 20090710	VARD - 20100225	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Thoracolumbar Spinal Pain	5299-5237	10%	Chronic T-Spine Pain…	5242-5010	10%	20091027	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

Chronic Thoracolumbar Spinal Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s gradual onset of his back condition began in August 2007 after repeated heavy lifting.  Radiographic studies in June 2008 and January 2009 showed mild degenerative changes in the lower back vertebrae.  There was no surgical indication.

At the 23 March 2009 physical therapy (PT) appointment, 6 months prior to separation, the CI reported mid-back (thoracic) pain rated 6/10 while seated, with flares to 8/10 when he stood or sat for greater than 30 minutes (though later in the examination this was reported as limited to 10 minutes).  This pain prevented running, lifting over 20 pounds, or marching with a ruck.  He experienced pain radiating into his ribs previously, but denied any pain at the time of the examination, and also denied any other radicular symptoms (bowel or bladder symptoms, numbness or tingling of either the upper or lower extremities).  Examination documented tenderness, guarding, and muscle spasms.  Gait and contour were not addressed.  Range of motion (ROM), taken over 3 repetitions with a goniometer, was recorded as flexion at 75 degrees (normal 90) and combined ROM at 185 degrees (normal 240), with pain limiting motion.  Neurologic examination was normal, including negative provocative testing for nerve root impingement.  

The 27 April 2009 MEB NARSUM examination, 5 months prior to separation, reported complaints of constant mid-back pain rated 6/10 at the examination, with flares to 9-10/10 brought on by lifting over 25 pounds or standing more than 15-20 minutes, but indicated the back pain did not interfere with activities of daily living.  The CI again denied radicular symptoms.  Physical examination reported a non-antalgic gait, mild tenderness of the spine at the mid-back, and no discernable spasm.  The CI reported pain at the end of ROM, but specific ROM measurements were not recorded.  Neurological testing was again normal, as was testing for nerve root impingement (negative for radiculopathy).  

At the 27 October 2009 VA Compensation and Pension (C&P) evaluation, performed 1 month after separation, the CI reported constant mid-back pain (he denied low back pain) rated 6-7/10 with flares to 10/10 precipitated by walking, twisting, running, or sitting for more than 15 minutes.  He indicated he could do no heavy physical activity or lifting, but denied incapacitating episodes.  Physical examination showed a normal gait and posture, with tenderness and spasm discernable on the mid-spine.  ROM after repetitive motion was recorded as flexion at 80 degrees and combined ROM at 220 with pain limiting motion.  Neurological examination was normal, and provocative tests for nerve root impingement were negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5237 (analogous to lumbosacral strain), citing limitation of forward flexion.  The VA rated the back condition 10% coded 5242-5010 (degenerative arthritis of the spine – arthritis due to trauma), based on the VA C&P examination 1 month after separation, citing painful motion of a major joint or group of minor joints.  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/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT and VA examinations (as well as tenderness reported at all examinations).  While muscle spasm was reported at the PT and C&P examinations, it was not 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).  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 back condition.  

BOARD FINDINGS:  In the matter of the chronic thoracolumbar spine pain 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 20160125, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013291, 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