RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00849
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041016

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E7, Supply Specialist, 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 - 20040720	VARD - 20050216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5237	10%	Lumbar Spine Degenerative Disk Disease	5237	20%	20040930	
Chronic Right Shoulder Pain	Not Unfitting	Right Shoulder, Subacromial Bursitis	5019	10%		
Gastroesophageal Reflux Disease		Gastroesophageal Reflux Disease	7346	0%		
Episodic Left Lower Abdominal and Flank Pain		Hysterectomy, Total Vaginal	7617	50%		
History of Depression		Depression, Not Otherwise Specified, Mild	9434	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s “chronic low back pain” condition began insidiously in 1991.  She was placed on quarters and treated with muscle relaxers.  In 1994 back pain recurred after a lifting.  In 1998 she complained of intermittent low back discomfort.  In June 2002 the CI developed pain after “lifting boxes in the field.”  Treatment consisted of a muscle relaxer, a nonsteroidal anti-inflammatory drug, amitriptyline (for nerve pain), and tramadol (an opioid-like medication).  Physical therapy was instituted in July 2002.  Magnetic resonance imaging (MRI) from 26 September 2002 revealed degenerative disc disease at L4/L5 and L5/S1 with mild ligamentum flavum (ligaments connecting the vertebrae) and facet joint hypertrophy.  At L4/L5 there was bilateral neural foraminal narrowing caused by hypertrophic posterior elements and by a lateral component of a disc bulge with potential impingement on the exiting left L4 nerve.  There was also a small disc protrusion at L5/S1.  Pain persisted and the CI received intramuscular Toradol (ketorolac, an NSAID) and Percocet (oxycodone, a narcotic, and acetaminophen, a pain reliever).  Treatment consisted of TENS (transcutaneous nerve stimulation) treatment, a back brace, and physical therapy.  Steroid injections were given with temporary relief.  X-rays on 1 March 2003, ordered for “lower back pain after assault” were normal.  Orthopedic evaluation on 1 October 2003 confirmed discogenic low back pain with intermittent radicular symptoms.  An MRI dated 29 March 2004 showed a broad based bulge of the L4-L5 abutting the exiting L4 nerve root was essentially unchanged and mild progression of the posterior protrusion of the L5-S1 disc, eccentric to the right, abutting and slightly displacing the right S1 nerve root.  Additionally, there was a mild compression deformity of the L2 vertebral body.  X-rays of the lumbosacral spine dated 30 March 2004 were normal.  A spine surgeon in April 2004 indicated there was nothing more to do. 

During the 6 May 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported recurrent back pain.  The examiner checked normal spine in the clinical evaluation.  The 1 June 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of low back pain and a weakness in both lower extremities associated with prolonged standing or sitting and a constant “pinch” sensation in both buttock areas, left worse than right.  She had no true pain radiation into her legs, just felt “numbness” down to her toes.  She had no bowel or bladder symptoms.  Physical examination range of motion (ROM) measurements showed forward flexion of 85, 88, and 86 degrees (normal 90), backward flexion of 30, 28, and 22 degrees (normal 30), left lateral flexion of 44, 40, and 42 degrees (normal 30), right lateral flexion 34, 32, and 37 degrees (normal 30), left lateral rotation 40, 38, and 40 degrees (normal 30), and right lateral rotation 50, 50, and 50 degrees (normal 30).  Deep tendon reflexes were equally active.  

At the 30 September 2004 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported chronic lumbar pain without any symptoms of any radiculitis.  She used a brace as needed.  She had to shift weight after sitting for 10-15 minutes.  She was able to stand in one place for 3-4 minutes maximum or even when dynamic walking, she had to sit down, relax, and stretch.   Physical examination showed a lordosis of the lumbar spine.  Forward flexion was 0-80 degrees, extension 0-30 degrees, lateral bending 0-30 degrees each side, and rotation 0-45 degrees each side.  Pain increased with repetition, which caused episodic spasms, but no radiation down the lower extremities.  With repetition there were episodic spasms and no radiation down the lower extremities, while ROMs for flexion and extension decreased by 15 degrees, lateral bending by 10 degrees, and rotation remained the same when gently done.  An MRI of the thoracic spine dated 31 January 2005 demonstrated early degenerative change of the T9-10 and T10-11 disks with a small posterior right paracentral disk bulge at T9-10 and an accentuation of the upper thoracic kyphosis (bending forward).  Examination on 17 May 2005, 7 months after separation, showed the thoracolumbar spine to be normal in appearance without tenderness and with a full active ROM without pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10%, coded analogously as 5237 (lumbosacral strain), citing tenderness on examination.  The VA rated the chronic low back pain condition 20%, coded 5237 (lumbosacral strain), based on the C&P examination 1 month before separation, citing limitation of forward flexion to approximately 60 degrees. 
The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 95 degrees, despite the VA rating that noted forward flexion to approximately 60 degrees when it was actually 65 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM and VA examinations proximate to separation.  Although there was muscle spasm on the VA examination, it was not 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.  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 “chronic low back pain” condition.  

Contended PEB Conditions:  Right Shoulder, Subacromial Bursitis; Gastroesophageal Reflux Disease; Episodic Left Lower Abdominal and Flank Pain; and History of 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, implicated in the commander’s statement nor 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 “chronic low back pain” condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended right shoulder, subacromial bursitis, gastroesophageal reflux disease, episodic left lower abdominal and flank pain, and history of depression 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 that 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 20160920, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170017095, 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. 

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

Sincerely,					      
						      					
Enclosure