RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00508
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20060103

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

CI CONTENTION:  “Cervical and lumbar injury (lumbar spinal fusion).”  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 - 20050929	VARD - 20060628	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5241	10%	Myofascitis, Lumbar Spine	5299-5237	10%	20050204	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record, Medical Evaluation Board (MEB) narrative summary (NARSUM) and addendum, the CI underwent an L5-S1 fusion in March 2005 for degenerative disc disease. At a 4 February 2005 VA Compensation and Pension (C&P) evaluation, 11 months before  separation and just prior to the fusion in March 2005, the CI reported progressive back pain that was constant and made worse with physical activity.  Physical examination showed forward flexion of 80 degrees (normal 90) and combined thoracolumbar range of motion (ROM) of 215 degrees (normal 240).  There was normal strength, sensation and reflexes with no evidence of muscle spasm or tenderness.  

The 14 April 2005 MEB NARSUM examination, 9 months prior to separation, noted complaints of constant pain.  Physical examination showed a normal gait and motor strength, mild tenderness and full ROM.  At a 24 May 2005 physical therapy (PT) visit, the CI had forward flexion of 40 degrees after repetition with a combined ROM of 145 degrees.  Pain was not addressed.  At a primary care visit, one day later, there was an antalgic gait with bilateral muscle spasm.  During the 19 July 2005 primary care visit, there was tenderness, painful motion and spasm, but gait was normal.  The primary care visit on 7 September 2005, 4 months prior to separation, revealed tenderness, bilateral paraspinal spasm, painful motion, abnormal posturing and an antalgic gait.  Nearly a week later a PT ROM study showed flexion of 60 degrees after repetition and a combined ROM of 185 degrees, limited by pain.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated the chronic back condition 10%, coded 5241 (spinal fusion), citing tenderness to palpation and decreased ROM due to pain.  The VA also rated the chronic back condition 10%, coded 5299-5237 (lumbar spine strain), based on the C&P examination 11 months before separation, citing flexion limited to 80 degrees.  

The panel agreed a 20% rating, but no higher, was justified for limitation of flexion greater than 30 degrees but not greater than 60 degrees as reported at the May and September 2005 PT ROM evaluations.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  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 recommends a disability rating of 20% for the chronic back condition, coded 5241.  

BOARD FINDINGS:  In the matter of the chronic back condition, the panel unanimously recommends a disability rating of 20%, coded 5241 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Back Pain	5241	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160818, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180000469, 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 and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,					      
						      					
Enclosure