RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01340
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050118

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

CI CONTENTION:  Requests review all conditions.  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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20041208	VARD - 20050817	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain…	5242	10%	Lumbosacral Strain	5237	20%	20021009	
Migraine Headache	Not Unfitting	Headaches	8100	NSC	20021009	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

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 November 1990 after she slipped and fell with exacerbations and re-injury in May 1991 from a fall, and in November 2000 when she slipped and fell off of a military vehicle.  

At the 9 October 2002 VA Compensation and Pension (C&P) evaluation, 27 months before separation, the CI reported numbness in both legs, sharp pain in her lower back, which radiated into her legs, and that these symptoms occurred on a daily basis.  Physical examination showed normal sensation and strength, and there was no radiation of pain, no muscle spasm, and no tenderness.  Straight leg raise test (SLR) was positive in both legs for radiculopathy.  Thoracolumbar spine range of motion (ROM) measurements showed a flexion of 45 degrees (95 normal) and a combined ROM of 115 degrees (240 normal).  The CI had a normal posture and a normal gait.  Radiographic (X-ray) studies showed a transitional L5 vertebra.  Magnetic resonance imaging (MRI) from 24 July 2003 showed a mild disc bulge at L3-4 through L5-S1 with most severe changes at L4-5, and mild central canal narrowing, with mild neural foraminal narrowing bilaterally.  

At the time of the 2 December 2003 VA neurosurgery clinic appointment, 14 months prior to separation, the CI reported sharp pain in the lower back that spread across both buttocks and down the posterior thighs.  She felt numbness down both legs whenever she stood for more than 5 minutes or walked about ¼ mile.  Physical examination showed ROM of “about 25% normal with pain at limits, tender to pressure…,” with SLR causing pain in the left lower back.  Strength and reflexes were normal in the lower extremities.  Sensation was noted as decreased pinprick and light touch in the entire left leg from the thigh to toe sparing isolated areas of the bottom of the foot and decreased on the right medial foot.  Electrodiagnostic testing (EMG/NCV) on 24 December 2004 showed no evidence of radiculopathy or peripheral neuropathy.  

At the time of the 8 April 2004 VA Physical Therapy (PT) clinic appointment, 10 months prior to separation, the CI reported that prolonged static positions increased her low back pain.  Physical examination showed limited extension, right side bending, and right rotation to 25%.  The CI had normal reflexes and normal strength, and sensation was intact.  Straight leg raise test was positive on the left.  The physical therapist noted that after treatment the CI had resolution of asymmetry along with increased active ROM to within normal limits.  

The 22 October 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of low back pain with radicular complaints.  Electrodiagnostic studies performed in February 2004 were negative.  A neurosurgery evaluation on 23 March 2004 determined that the CI was not a surgical candidate.  Physical examination showed “tenderness in the lumbar area with motor, sensory, reflexes, straight leg, heel and toe walk intact.”  ROM measurements showed flexion of 40 degrees (normal 90) and a combined ROM of 170 degrees (normal 240).  The examiner reported that MRI in September 2003 showed mild disc bulges at L3 through L5-S1, most significant at L4-5.  The examiner gave a diagnosis of “lumbar degenerative disc disease, pain is slight and constant.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), citing thoracolumbar ROM limited by pain and tenderness to palpation.  The VA rated the back condition 20%, coded 5237 (lumbosacral strain), based on the C&P examination 27 months before separation, citing limitation of forward flexion.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees and combined ROM not greater than 120 degrees), as reported on the MEB NARSUM examination.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  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 low back pain condition coded 5242.  

Contended PEB Condition:  Migraine Headache.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the non-medical assessment or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the low back pain condition, the panel unanimously recommends a disability rating of 20%, coded 5242 IAW VASRD §4.71a.  In the matter of the contended migraine headache condition, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain	5242	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161005, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180002713, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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 the Department of Veterans Affairs.

Sincerely,					      
Enclosure