RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00359
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070801

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

CI CONTENTION:  “Review all conditions.”  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 - 20070615	VARD - 20070919	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5239	10%	L5-S1 Spondylolisthesis	5238	10%	20070803	
			C5-6 Lordosis	5239	NSC		
Chronic Left Wrist Pain	Not Unfitting	Left Wrist Strain	5215			
Chronic Neck Pain	Not Unfitting	No VA Placement		
Chronic Right Shoulder Pain	Not Unfitting	Right Shoulder Degenerative Joint Disease		
Chronic Bilateral Knee Pain		Bilateral Knee Strain	5257	NSC		
Chronic Left Ankle Pain		Left Ankle Strain	5271			
Chronic Headaches		Headaches	8100			
Chronic Depression		Depression	9435			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP began in 2000 without specific injury or trauma. On September 2006, X-rays documented degenerative disc disease (DDD) with grade I spondylolisthesis (< 25% slippage) at L5-S1 vertebral levels.  Magnetic resonance imaging in November 2006 confirmed DDD at L4-L5 and L5-S1 with no evidence of disc herniation or nerve compromise.  At a December 2006 neurosurgery evaluation, physical examination showed full lumbar range of motion (ROM), normal gait, strength and reflex testing.  

The 14 may 2007 MEB NARSUM examination, 3 months prior to separation, noted CI complaints of worsening LBP.  Physical examination showed full ROM, a normal heel-toe walk, and no evidence of muscle spasm.  

At the 3 August 2007 VA Compensation and Pension (C&P) evaluation, performed 2 days after separation, physical examination showed flexion to 80 degrees (normal 90) with no evidence of painful motion, radiating pain, fatigue, weakness, or lack of endurance.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5239 (spondylolisthesis or segmental instability), citing full ROM without radiculopathy or muscle spasms.  The VA also rated the back conditions 10%, coded 5238 (spinal stenosis), based on the C&P evaluation 2 days after separation, citing 80 degrees of flexion and 30 degrees of extension.  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) reported at the C&P evaluation proximate to separation.  A 20% rating was not supported as there was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of a higher rating under the alternate VASRD formula for IVDS.  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  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.  

Contended PEB Conditions:  Wrist, Neck, Right Shoulder, Bilateral Knee, and Left Ankle Pain; Headaches; Depression.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends there be no re-characterization of the CI’s disability and separation determination.  

AR20170015427, 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.
A copy of this decision has been provided to the counsel you listed on your
application,