RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01426
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040617

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an  active duty E4, Human Intelligence Collector, medically separated for “chronic 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 - 20040416	VARD - 20040921	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	10%	Lumbar Spine L4-S1, DDD	5242	10%	20040921	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 2000 without specific injury or trauma.  Lumbar spine X-rays in November 2001 were normal, but an MRI in October 2002 revealed degenerative disc disease with an annular tear and disc protrusion at L4-L5.  Surgery was not indicated.  At the MEB NARSUM examination, completed on 10 February 2004, (dated 4 March 2004), 4 months prior to separation, the CI stated, “I have degenerative disc disease in my lower back,” and reported constant low back pain (LBP) rated at 3/10.  Physical examination showed tenderness along the paralumbar muscles as well midline from the mid-thoracic to the S1 level and at the bilateral sacroiliac joints.  Reflexes, strength and sensation were normal.  The examiner referred to the 24 February physical therapy (PT) range of motion (ROM) evaluation which recorded 70 degrees of flexion (normal 90) and a combined ROM of 175 degrees (normal 240).  The CI complained of pain with extension.

At the 21 September 2004 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported continued daily back pain.  Physical examination showed flexion to 90 degrees and slight muscle spasm.  There was no radiating pain down to the lower extremities.  The CI had a normal gait and ambulated without an assistive device.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing tenderness and ROM accompanied by pain.  The VA rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 3 months after separation, citing 90 degrees of forward flexion.  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 PT and VA examinations proximate to separation.  Although there was muscle spasm, it was not 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 LBP condition.  

BOARD FINDINGS:  In the matter of the chronic 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 

AR20180001590, 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