RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00217
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041124

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

CI CONTENTION:  The CI contends his rating has not changed from the original date of separation, but his disability has worsen.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited 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.  Any conditions outside the Board’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 Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations 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 at the time of separation.  The Board 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 Board 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 - 20040805	VARD – 20070911 (Out of Range)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Low Back Condition	5237	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Chronic Low Back Pain Diagnosis.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in November 2002 while performing sit-ups. The CI reported he felt a pop and severe pain when coming to a sitting position with recurring low back pain since the initial injury.  Magnetic Resonance Imagining (MRI) 16 November 2002 revealed degenerative disc disease at L2-L3 with a posterior radial annular tear at L5-S1.  No evidence of disc herniation or thoracic spine abnormality.  MRI on 15 February.2004, revealed degenerative disc disease and degenerative facet arthropathy in November 2002. 

At the MEB examination (recorded on DD Forms 2807 and 2808) dated June 2004, 5 months prior to separation, the CI reported chronic back pain with shooting pain and tingling down his leg. Physical exam showed positive tenderness to palpation of the lumbar spine, and decreased range of motion 

The MEB NARSUM examination on 7 June 2004, 5 months prior to separation, noted complaints of severe pain and inability to pass the APRT.  Physical examination showed normal gait, tenderness to palpation over the spinous processes but no tenderness over the paravertebral muscles.  Heel and toe walk was normal.  Lower extremity strength was normal except for the great toe which was 4/5.

Physical therapy (PT) ROM recorded July 2004, 4 months prior to separation, documented combined ROM of 178 degrees (normal=240), with flexion of 40 degrees and pain present throughout ROM testing.

At the 21 October 2004 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported no paresthesia or bowel/bladder dysfunction.  Functional impairment included lifting, ambulating long distances, jumping, stretching, and bending.  Medication provided some benefit.  Physical exam documented radiating pain on movement without muscle spasm or tenderness to palpation.  No signs of radiculopathy.  No limitations due to fatigue, weakness, lack of endurance, or incoordination.  Muscle strength was 5/5 and reflexes 2+.  Sensation normal to pinprick and light tough.  ROM documented normal combined ROM with 90 degrees of flexion (normal=90).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing range of motion limited by pain, tenderness to palpation over the spinous processes, and no focal neurological deficits.  The VA did not provide a rating until 3 years after separation, which was out of range for panel’s consideration.

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, or combined ROM greater than 120 degrees but not greater than 235 degrees) reported on the VA, examination proximate to separation, and the PT ROM exam (combined ROM).  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 (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  The CI had normal nerve studies (EMG, NCV).

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 back condition and IAW VASRD §4.71a, the Board 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160412, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	
AR20170014136,. XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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