RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01300
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040403

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E5, Motor Transport Operator, medically separated for “low back pain” with a disability rating of 10%. 

CI CONTENTION:  “Lumbar Degeneration, Major Depressive Disorder, Bilateral Ankle strain.”  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 - 20040219	VARD - 20040817	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Lumbar Strain, Degenerative Joint Disease	5242	10%	20040526	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

Chronic Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in July 2003 when the CI was involved in a motor vehicle accident.  Following the accident the CI was placed and quarters and prescribed physical therapy and anti-inflammatory medication.  On 5 August 2003 x-ray studies showed normal lumbar spine series.  On 18 November 2003 Magnetic Resonance Imaging (MRI) of the lumbar spine was normal.

The 9 January 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of low back pain, muscle spasms, and numbness and tingling sensation to right foot.  Physical examination showed some tenderness in the right paravertebral lumbar region.  Straight leg raise test (test for herniated disc) was negative for radicular pain, sensory findings were normal and deep tendon reflexes were 2+ to lower extremities.  CI could walk on his heels and toes.  Range of motion showed lumbar flexion 95 degrees (normal 90), extension 30 degrees (normal 30), right side bend 15 degrees (normal 30), left side bend 10 degrees (normal 30), right rotation 30 degrees (normal 30), and left rotation 45 degrees (normal 30).  

At the 26 May 2004 VA Compensation and Pension (C&P) evaluation, 1 month after separation, the CI reported low back pain without radiation.  Physical examination showed tenderness to the midline of the lower lumbar spine.  Range of motion showed forward flexion 90 degrees (normal 90), extension 20 degrees (normal 30), and right and left rotation 25 degrees (normal 30).  Straight leg raise was negative.  Reflexes were 2+ in lower extremities, no atrophy of calf or thigh, and motor and sensory “okay”.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PEB condition 10%, coded 5299-5237 (analogous to lumbosacral strain), citing combined range of motion 225 degrees.  The VA also rated the back condition 10%, coded 5242, (degenerative arthritis of the spine) based on the C&P examination 1 months after separation, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 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 85 degrees) as reported on the NARSUM and VA 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.  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 back condition.  

BOARD FINDINGS: In the matter of the 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.  Therefore, the panel recommends 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 20160929, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180005833, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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