RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00608
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040625

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Satellite Communication System Operator and Maintainer, medically separated for “mechanical low back pain” with a disability rating of 0%.

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 conditions 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 - 20040316	VARD - 20040923	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Low Back Pain	5299-5237	0%	DDD, Lumbar Spine	5243	20%	20040330	
History of Migraines	Not Unfitting	Migraine Headaches	8100	NSC	20040330	
Remote History of Exercise-Induced Asthma	Not Unfitting	Asthma	6602	NSC	20040330	
Overweight	Not Unfitting	No VA Placement	
History of Arnold-Chiari Type I Malformation			
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Mechanical Low Back Pain (LBP).  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 1998 after heavy braking to avoid a motor vehicle accident.  X-rays of the thoracic and lumbar spines on 27 January 2003 were unremarkable.  The CI was seen in neurology on 15 July 2003 and noted to have a normal neurological examination and gait The CI was seen in neurology on 15 July 2003 and for a neurosurgery consult on 19 August 2003 and noted to have a normal neurological examination and gait during both examinations.  An MRI of the lumbosacral spine was normal on 16 September 2003.  A physical therapy range of motion (ROM) study on 30 October 2003 showed 70 degrees of flexion (normal 90).  At the 12 November 2003 orthopedics appointment, the CI reported LBP and occasional numbness in his right leg.  It was noted he had had three MRIs, physical therapy, and electrodiagnostic studies without significant findings other than an incidental cyst in his spine.  The physical examination was unremarkable.  The examiner reported “basically from an orthopedic standpoint I really have nothing that I can offer him at all.  If he is going to be released from the military it would have to be through a psychiatric release not through an orthopedic release because I don’t have anything on which to base a need for him to have a permanent profile for other than the pain and I cannot measure or quantitate the pain.”  In physical therapy on 11 December 2003, the therapist noted the LBP was not improving and that all physical therapy efforts had been exhausted.  A repeat MRI on 14 January 2004 showed some congenital variants, but did not reveal nerve impingement.  Mild degenerative disc disease (DDD) was present as well.  

During the 20 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported recurrent back pain.  The physical examination showed normal strength and reflexes.  The CI was able to heel/toe walk and ROM measurements showed a normal flexion of 90 degrees, and a combined ROM of 160 degrees (normal 240).  

The 4 March 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of LBP.  The physical examination showed the CI had a normal gait and spinal contour without muscle spasms.  ROM testing showed a normal flexion of 90 degrees and a combined ROM of 150 degrees.  There was no tenderness and reflexes and strength were normal.  It was noted the CI needed some assistance performing a squat, but it was not recorded if this was due to weakness or pain.  

At the 30 March 2004 VA Compensation and Pension (C&P) evaluation, 3 months before separation, the CI reported constant LBP with radiation down the right leg.  Incapacitation was not recorded.  One examination entry noted the gait as antalgic but then multiple entries noted it as normal.  The panel could not find evidence to explain this discrepancy.  ROM testing showed a flexion of 50 degrees and a combined ROM of 150 degrees.  The CI was able to stand on his toes and heels and had normal reflexes and strength.  Neither spasm nor atrophy was recorded.  Tenderness was present.  The examiner did not record any reason for the decreased flexion seen on this examination as compared to previous measurements.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, analogously coded 5237 (lumbosacral strain), citing full flexion with mild limitation of extension, rotation and side bending.  The VA rated the back condition 20%, coded 5243 (intervertebral disc syndrome), based on the C&P examination 3 months before separation, citing ROM limitations.

The preponderance of examinations supported a 10% rating for either the limitation in motion or for tenderness.  These examinations were also consistent with the pathology in evidence.  The VA examination supported a 20% rating, but was an outlier from other examinations and offered no explanation for the reduction in motion.  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 combined ROM greater than 120 degrees but not greater than 235 degrees as reported on the physical therapy and MEB NARSUM examinations.  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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the low back condition, coded 5237.  

Contended PEB Conditions:  Overweight, Migraines, Arnold-Chiari Type I Malformation, and Exercise-Induced Asthma.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None were profiled or implicated in the commander’s statement and all were judged to meet 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 there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the low back condition, the panel unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended overweight, migraines, Arnold-Chiari Type I Malformation, and exercise-induced asthma 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 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	
Mechanical Low Back Pain	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160913, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180000471, 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