RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00969
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040423

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

CI CONTENTION:  The condition continues to worsen.  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 -20031209	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical LBP	5237	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY: 

Chronic Mechanical LBP.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP began in October 2000 after offloading a tent from a truck during a training exercise.  There was no surgical indication.  The 21 April 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 12 months prior to separation was unremarkable.  The 16 May 2003 MEB NARSUM examination, 11 months prior to separation, noted complaints of constant, dull, itching, burning pain that affected the entire lower back with a severity of 8/10.  The CI also reported intermittent radicular pain down the left hip and thigh.  Exacerbating factors included running, jumping, marching, wearing field gear, carrying a rucksack, and lifting greater than 15 pounds. 

Physical examination showed tenderness in multiple lower back areas to include the posterior L5-SI axial central elements, bilateral posterior superior ilaic spine regions and bilateral iliocostal paraspinals.  The examiner noted the CI walked slowly with hips held in flexion.  Sensation was intact to light touch and pinprick throughout both lower extremities with 5/5 strength bilaterally.  Straight leg raise at 30 degrees bilaterally reproduced the back pain symptoms only.  Waddell’s signs were 2 of 5.  Range of motion (ROM) testing using bubble goniometry recorded 40 degrees forward flexion (normal 90), 5 degrees extension (normal 30), and 35 degrees right and left lateral bend (normal).  Right and left rotation were not recorded.  Painful motion was not specifically mentioned.  Spinal contour was noted as “roughly” normal.  There was no VA Compensation and Pension evaluation proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP 10%, coded 5237 (lumbosacral or cervical strain), citing painful motion. The panel agreed a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) or muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour as reported on the NARSUM examination.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the LBP condition, coded 5237.  

BOARD FINDINGS:  In the matter of the LBP condition, the panel unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  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	
LBP	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160921, with attachments
Exhibit B.  Service Treatment Record

AR20170018910, 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