RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00866
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050206

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

CI CONTENTION:  The CI contended that the back injury was severe enough to warrant discharge, as well as release from his assigned task force.  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 - 20041103	VARD - 20050309	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain with L5/S1 Herniated Disc with Left S1 Nerve Root Impingement	5237	10%	Herniated Lumbar Disc with Spinal Canal Stenosis	5243	0%	20041123	
	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Back Pain with L5/S1 Herniated Disc with Left S1 Nerve Root Impingement.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began in May 2003 after a motor vehicle accident.  Neuroimaging showed a compression fracture of L2 and separated ribs.  He received a week of convalescent leave, a 30-day profile, and a medication for muscle relaxation.  He returned to his job, which required heavy lifting and manual labor.  According to his commander his back pain worsened and he had difficulty performing his job.  On 12 January 2004, magnetic resonance imaging (MRI) demonstrated degenerative disc disease (herniation at L5/S1 with mild to moderate stenosis, congenitally short pedicles, and a minor avulsion fracture off the L2 endplate).  On 24 June 2004, computed tomography (CT) showed a chronic appearing, commuted corner fracture of the anterior superior endplate of the L2 vertebral body.

During the 12 August 2004 MEB examination (recorded on DD Forms 2807 and 2808) 6 months prior to separation, the CI reported back pain with almost constant numbness and tingling from the back of the left thigh and leg.  Physical examination showed a slow walking individual with tenderness to palpation in the left lumbosacral area; however, strength, sensation and reflexes were all normal.  The CI also reported pain with 3/5 examination maneuvers not expected to elicit pain based on the known pathology (Waddell’s sign) 

The 12 August 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of severe back pain the day of the examination with pain radiating down into the left leg with severe numbness and tingling at times.  Physical examination showed he could stand on his heels as well as his toes.  He had a positive straight leg raise (SLR) on the left leg and his left ankle jerk was decreased and almost absent compared to the right side.  The other reflexes were normal.  Active range of motion (ROM) showed flexion to 9 degrees (a likely typo with actual 90 degrees-normal 30), extension 30 degrees (normal 30) and the other ROMs were also normal.  Findings were compatible with left S1 radiculopathy and moderate spinal canal stenosis.  The 4 October 2004 MEB NARSUM Specialty Care examination, 4 months prior to separation, noted complaints of severe back pain the day of the examination; with pain radiating down into the left leg with severe numbness and tingling at times.  The CI reported a TENS unit did not help.  There was no history of bladder or bowel dysfunction.  The physical examination showed ROM flexion of 90 degrees, extension of 10 degrees.  Pain with extension was reported.  Positive deep tendon reflex (DTR) on the left was decreased and almost absent, as was the ankle jerk.  Straight leg raise on the left was 60 degrees and on the right was 56 degrees.  He had a positive Lasegue sign [SLR] (test for underlying herniated disk) on the left.  The CI could stand on heel and toes.  

At the 23 October 2004 VA Compensation and Pension (C&P) evaluation, 4 months before separation, the CI reported no awareness of any signs or symptoms related to spinal stenosis and his recreations included running, hiking and swimming; with no immediate stress from heavy physical activities.  There was no left foot or knee condition that interfered with his posture or gait, activities of daily living, or service functions.  In general, he could sustain heavy physical activities without immediate distress.  Physical examination showed normal gait and posture, strength, sensation and reflexes.  ROM was 90 degrees of flexion and 240 combined (both normal).  Spinal curvature was maintained and paraspinal muscles were not in spasm.  There was no lower extremity muscle spasm and muscle function was equal bilaterally.  SLR was negative bilaterally.  There was no radiation pain on movement.  ROM was normal and without restriction.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “back pain” condition 10%, coded 5237 (lumbosacral or cervical strain).  The VA rated the “herniated lumbar disc with spinal canal stenosis” condition 0%, coded 5243 (intervertebral disc syndrome), based on the C&P examination 3 months before separation, citing a non-compensable evaluation.  The panel agreed that a 10% rating, but no higher, was justified for limitation combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM examination.  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 in the service treatment records 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.  

BOARD FINDINGS:  In the matter of the “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 20160920, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170017105, 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