RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01317
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040331

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

CI CONTENTION:  The CI made no specific contention.  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 - 20031219	VARD - 20050223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Chronic Lumbosacral Strain	5237	10%	20041006 	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began as a strain injury in March 2002 during basic training.  There were significant inconsistencies found in provider accounts regarding the mechanism and onset timing.  The MEB NARSUM patient interview and other STR provider notes documented a re-injury (twisting) in November 2002 resulting in a civilian hospital admission due to severe pain.  The hospital admission records did not mention a re-injury, and the emergency department record cited intractable chronic pain, and the CI’s desire to “get to the bottom of this.”  Multiple X-rays and two MRIs were interpreted as normal.  A myofascial etiology was presumed, but not confirmed, and muscle spasm was not documented in any STR provider notes.

Multiple earlier STR entries documented normal range of motion (ROM), but entries during and for a few months after the aforementioned hospital admission documented severe ROM limitation but with inconsistencies.  The hospital discharge note described the CI as walking in a flexed condition with the inability to stand erect while at the same time documenting “no lumbar muscle spasm.”  A civilian physical therapy (PT) note on 28 February 2003 documented “moving very slowly and bent over … essentially zero-lumbar ROM … any movement causes severe pain … severe muscle guarding [without note of spasm];” however, a service primary care entry on the same day recorded “mild distress secondary to exercise.”  

There were multiple STR entries over an 8-month interval between the above period and the formal MEB PT ROM examination.  Although none of those entries commented directly on ROM or gait, none of them were suggestive of severe (or even significant) ROM limitation or of gait or posture disturbance.  Entries during this interval noted the CI was responding favorably to treatment, and X-ray reports were normal with no mention of abnormal contour (reflecting spasm or a stooped posture). There were no incapacitating episodes documented after the aforementioned hospital admission.  

The 20 November 2003 MEB PT examination, 5 months prior to separation, revealed repetitive ROM of flexion to 25 degrees (normal 90) and combined ROM was 155 degrees (normal 240).  Gait, posture, tenderness, spasm, and painful motion were not addressed.  The PEB’s DA Form 199 decision cited a combined ROM of 269 degrees, but the source examination for those measurements was not in evidence.  

The 21 November 2003 MEB NARSUM examination documented complaints of constant back pain rated 5-6/10.  The pain was exacerbated by “turning” and relieved with stretching, and rendered the CI unable to “sit for extended periods” or take the fitness test.  The permanent L3 profile, dated 6 August 2003, prohibited fitness testing, but the commander’s statement (dated 3 days prior to the MEB NARSUM) lauded the CI’s past performance on fitness tests.  The last fitness test scores in evidence (mid-2002, preceding hospital admission) documented 45 push-ups and 82 sit-ups.  The MEB NARSUM physical examination revealed a normal gait and neurological findings (5/5 strength), and referred to the MEB PT ROM examination without providing any additional findings.  A civilian PT note dated 31 August 2004, 4 months after separation, documented “all trunk ROM is within normal limits,” noted an antalgic gait, and that the CI had not been compliant with earlier treatment.  

The 6 October 2004 VA Compensation and Pension (C&P) evaluation, 6 months after separation, documented “spinal discomfort” rated “2/10 on most days” with transient monthly exacerbations to 10/10 upon prolonged standing or sitting.  Physical examination recorded a normal gait, no spinal tenderness, and normal neurological findings.  ROM was flexion to 70 degrees and combined ROM was 200 degrees; painful motion was present.  Spinal contour and muscle spasm were not addressed.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s rated the low back condition 10%, coded 5237 (lumbar strain), citing spinal tenderness.  The VA’s rated the low back condition 10%, also coded 5237, based on the C&P examination 6 months after separation, citing limitation of motion.

The panel agreed there was insufficient evidence (applicable to the time of separation) for gait disturbance, abnormal spinal contour, or incapacitating episodes to support a rating higher than the PEB’s 10%.  The panel deliberated whether the ROM evidence from the MEB PT evaluation was sufficiently probative to justify a rating based on the §4.71a 40% criterion of “flexion...30 degrees or less.”  Members agreed the severe ROM limitation (flexion 25 degrees) documented in the MEB PT examination was inconsistent with the observed normal gait and lack of objective evidence for spasm or other expected findings.  The severe ROM limitation was not convincingly explained by re-injury or other clinical exacerbation of a chronic condition associated with the modest functional limitations and much better ROM for periods both before and after the MEB PT evaluation.  The C&P evidence, conversely, was more detailed and compliant with VASRD rating guidelines as well as more consistent with the overall STR evidence, and it was corroborated by the post-separation civilian PT evidence. The panel therefore agreed, with respect to ROM criteria, the determinate probative value for its recommendation should be assigned to the C&P evidence that was aligned with §4.71a criteria for a 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain condition.  

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.  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 20160928, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180001386, 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