RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE: pd-2016-00853
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20041018

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

CI CONTENTION:  Current condition supports a higher rating. 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 - 20040310	VARD - 20050224	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Low Back Pain	5237	10%	Low Back Strain w/ Sacroiliac Dysfunction	5237	10%	20040930	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Low Back Pain (LBP).  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI slipped on a wet floor and injured her back in 2001 and again fell in 2002 causing an exacerbation of prior LBP.  At the time of her second fall, the CI denied any acute bowel or bladder symptoms, peripheral numbness, or any other non-spinal complaints.  Spinal x-rays were normal.  Failure to respond to conservative treatment, the CI underwent MEB. 
   
The 14 July 2004 MEB NARSUM examination, 3 months prior to separation, noted low back pain that was relieved with rest or prescribed narcotics.  Her pain was aggravated by standing more than 20 minutes, lifting over 15 pounds or when running.  Her physical examination (PE) was documented on the DD Form 2808 dated 13 May 2003, 5 months before separation.  This examination revealed spinal tenderness.  Straight leg raise testing for radiculopathy was negative and sensory testing was intact.  Motor strength was 5/5.  Spinal range of motion (ROM) was documented as “full”.  Painful motion, gait, spinal contour, and muscle spasms were not addressed.  During the 29 July 2004 physical therapy (PT) evaluation, 3 months before separation, the CI reported aching and stabbing back pain with occasional radicular symptoms.  Her PE revealed forward flexion to 75 degrees (normal 90) and combined 195 degrees (normal 240); painful motion was present.  Lower extremity strength was normal.  The examiner also documented the CI bent forward easily to remove her boots, smooth trunk ROM, and moved easily throughout transfers from sit to stand and vice versa.  

At the 30 September 2004 VA Compensation and Pension (C&P) evaluation, less than 1 month before separation, the CI reported LBP with intermittent radicular pain into the right leg two times per month.  There was no bowel or bladder dysfunction.  Her PE revealed a normal gait, no spinal tenderness, and normal sensation.  ROM of the lower spine was painful and measured as extension at 15 degrees (normal 30), bilateral lateral flexion of 20 degrees each side (normal 30), and normal forward flexion and bilateral rotation.  The combined ROM was 195 degrees.  Spinal contour and muscle spasms were not addressed. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition at 10%, coded 5237 (lumbosacral strain), citing spinal tenderness.  The VA utilized the same code and also rated the low back condition at 10%, based upon the C&P examination less than 1 month before separation.  Panel members 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 PT and VA pre-separation 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.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula.  Finally, there was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The panel therefore concluded that an additional disability 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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.

BOARD FINDINGS:  In the matter of the mechanical low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were 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 20160919 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170017098, 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