RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01411
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20041128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Shower/Laundry and Clothing Repair Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:  Review his unfitting back condition.  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 - 20040729	VARD - 20050708	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5242	10%	Chronic Active Lumbosacral Strain Myositis, DDD …, HNP …	5243	20%	20050328	
 COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in 2003 while lifting sandbags in preparation for a unit move into Iraq.  He was medically evacuated to Germany in November 2003 for another condition where he was also evaluated for low back pain.  X-rays in December 2003 were normal.  He was treated with physical therapy for muscle spasms.  He was returned to his home station where he continued with physical therapy which reportedly increased his back range of motion (ROM) without alleviating his pain.  Electrodiagnostic studies done in January 2004 were normal.  

At the 4 December 2003 primary care clinic evaluation, the CI complained of recurrent back pain.  Physical examination showed tenderness over the lumbosacral spine with muscle spasms.  As charted below, flexion was 90 degrees (normal) with extension to 15 degrees (normal 30) with intact rotations (lateral flexions were not recorded).  At the 10 December 2003 Physical Medicine and Rehabilitation evaluation, the CI reported back pain of 7/10 that worsened with activity or prolonged standing.  Physical examination showed a normal gait.  There was lumbar tenderness and “limited flexion hand to thigh with marked back pain” with extension to 20 degrees (normal 30) and full active rotation on both sides.  An MRI of the lumbar spine on 9 March 2004 showed herniated discs at L4-5 and L5-S1 levels with disc bulges resulting in bilateral neural foraminal stenosis.  

During the 27 April 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, and on the 27 May 2004 NARSUM examination, 6 months prior to separation; the CI reported persistent low back pain described as a sharp and burning sensation on the right side of his lumbar area that increased with prolonged sitting or standing as well as bending and lifting objects.  Changing positions, taking medications and using the TENS machine helped alleviate the pain.  He described his pain as 5-6/10 at worst, occurring approximately one per week during flare-ups.  Physical examination showed a normal gait and some limitation and pain with forward flexion (see chart below).  

At the 22 March 2005 VA Compensation and Pension evaluation, 4 months after separation, the CI reported continued pain in the lumbosacral area that had become more severe in intensity and more frequent.  He described the pain as sharp and shock-like in sensation and rated at an intensity of 6/10.  He described weekly flare-ups that were at 9/10 intensity.  The CI was not using a cane or assistive device and reported that he was able to walk for 30-45 minutes.  The examiner noted that his thoracolumbar ROM was limited (see chart below) with pain elicited during measurement.  There was tenderness to palpation of the lumbosacral area at the paravertebral muscles.  Repetition elicited increased pain without evidence of weakness or lack of endurance.  There was a normal gait and no spasm was noted.  

The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	PCC ~ 11 Mo. Pre-Sep	PM&R ~11 Mo. Pre-Sep	MEB ~6 Mo. Pre-Sep	VA ~4 Mo. Post-Sep	
Flexion (90 Normal)	90	“hand to thigh”	75	50	
Combined (240)	>120; <235	>120; <235	225	170	
Comments	Painful motion; Spasm	Tenderness; Painful motion	Painful motion	Tenderness; Painful motion	
§4.71a Rating	10%	20%	10%	20%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded analogously 5299-5242 (degenerative arthritis of the spine), citing combined ROM.  The VA rated the low back condition 20% coded 5243 (intervertebral disc syndrome), based on the C&P examination 4 months after separation, citing limitation of motion.  

In assigning probative value to these somewhat conflicting examinations, the panel noted that the limitation of thoracolumbar motion recorded in the MEB NARSUM examination met the threshold for a 10% rating.  The MEB and NARSUM were both conducted by the same examiner, listed the same values without noting repetition and appeared to be a single examination.  However, the VA examination proximate to separation was more detailed, reported ROM performed after repetitive motion, was more consistent with outpatient notes and more reflective of the anticipated severity based on the clinical pathology.  Therefore, the panel placed greater probative value on the VA examination.  

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), as reported on the VA examination.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that 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 condition, coded 5299-5242.  

BOARD FINDINGS:  In the matter of the low back condition, the panel unanimously recommends a disability rating of 20%, coded 5299-5242 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	5299-5242	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161004, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment 

AR20180001581, 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.

Sincerely,					      
Enclosure