RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01369
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Trainee, medically separated for “chronic low back pain” with a disability rating of 0%.

CI CONTENTION:  “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(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 (VA), 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 - 20031203	VARD - 20041019	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	0%	Chronic Lower Back Pain with Mild Protrusion of the Annuli at L4-L5 and L5-S1	5299-5237	10%	20040714	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in basic training while doing a one-armed push-up.  An MRI of the thoracic spine was negative and the lumbar spine showed minimal disc protrusion at L4-L5 and L5-S1.  At the 12 September 2002 sports medicine evaluation, the diagnosis was somatic dysfunction of the lumbar and thoracic spines and recommended conservative treatment.  

The 29 October 2003 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain with lifting heavy objects in excess of 40 pounds and standing or walking extended periods of time.  Physical examination showed normal spinal alignment.  The CI was able to walk on his “heels and toes without problem.”  The examiner noted tenderness to palpation (TTP) in the lumbosacral area.  There was no sacroiliac joint pain and no radiation of pain to the lower extremities.  Provocative exam maneuvers to elicit radicular pain were negative.  At the 2 December 2003 physical therapy range of motion (ROM) evaluation, physical examination showed forward flexion 90 degrees (normal 90) and extension 30 degrees (normal 30) after repetition.  Lateral flexion and rotation measurements were not reported.  There was also no documentation of painful motion. 

The 14 July 2004 VA Compensation and Pension examination, 5 months after separation noted complaints of lumbosacral spine pain that did not radiate to the lower extremities.  The CI reported that LBP flared with bending and lifting.  He denied bladder or bowel complaints and said he could walk normally.  On physical examination there was a normal gait.  The CI was able to heel and toe walk without difficulty.  There was TTP of the lumbar spine.  There was no muscle spasm or radiation of the pain to the lower extremities.  The examiner noted there was painful, limited ROM with flexion 80 degrees and combined ROM of 220 degrees (normal 240) and with repetitive motion there was increased pain and easy fatigability, with loss of “at least 5 more degrees” ROM with repetition.  Provocative tests to elicit radicular pain were negative. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5299-5237 (analogous to a lumbosacral strain), citing “without neurologic abnormality, forward flexion of 90 degrees.”  The VA rated the back condition 10%, coded 5299-5237, based on the STR, citing “tenderness in the mid and lower lumbosacral area and evidence of recurrent pain with strenuous activities.”  There was evidence of tenderness of the lumbosacral spine noted at the MEB NARSUM examination to support a 10% rating based on “localized tenderness not resulting in abnormal gait or abnormal spinal contour.”  The post separation VA examination also supported a 10% rating based on localized tenderness or flexion of the TL spine “greater than 60 degrees but not greater than 85 degrees” and combined range of motion of the TL spine “greater than 120 degrees but not greater than 235 degrees.”  The panel next reviewed to see if a higher rating than 10% was supported, but there was no evidence at either the MEB NARSUM or VA examinations of TL flexion not greater than 60 degrees or combined TL ROM not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or an abnormal spinal contour.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating based on incapacitating episodes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the back condition, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the back condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  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	
Chronic Low Back Pain	5299-5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160925, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180001403, 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 to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX.

Sincerely,	
Enclosure