RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00682
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20041030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve, E4, Automated Logistical Specialist, medically separated for “chronic subjective back pain…” with a disability rating of 10%.  

CI CONTENTION:  No specific contention made.  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 - 20040603	VARD - 20050908	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Back Pain…	5299-5237	10%	Chronic Low Back Pain, Paralumbar Muscle Spasms…	5237	NSC	20050826	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Subjective Back Pain.   According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in January 2003 after moving equipment.  He was treated with medications, physical therapy, and duty limitations, but his pain persisted.  X-rays of the lumbar spine were normal.  In October 2003, he was noted to have a non-antalgic gait (not abnormal due to pain, implying a normal gait), full but painful range of motion (ROM), and an essentially normal neurological examination.  An MRI in December was significant for minimal degenerative disc disease at L4-5 and L5-S1.  Straightening of the lumbar spine was noted; this was consistent with spasm.  

During the 24 April 2004 MEB NARSUM examination, 6 months prior to separation, the CI reported lower back pain with physical activity.  He did well as long as he didn't do any strenuous physical activities; he had not missed work as a civilian respiratory therapist.  The physical examination was normal with a normal neurological examination and full ROM.  Tenderness or signs of nerve root irritation on provocative examination were absent.  Gait and spasm were not documented.  

At the 26 August 2005 VA Compensation and Pension (C&P) evaluation, 10 months after separation, the CI reported constant lower back pain.  The physical examination showed a normal gait, neurological examination, ROM, and spinal contour.  Paraspinal muscle spasm was absent.  Provocative maneuvers for nerve root irritation were negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded analogously to 5237 (lumbosacral strain), citing a normal combined thoracolumbar ROM without neurologic abnormality.  The VA determined the low back condition was not service-connected.  

There was no limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine and the MEB and VA C&P examinations did not note the presence of painful motion, muscle spasm, guarding or localized tenderness.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height, nor was there evidence of additional functional loss that would impact functioning in the average civil occupation.  The panel concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

PANEL FINDINGS:  In the matter of the low back condition 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 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 20160913, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170016357, 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