RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01458
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040910

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, M1 Armor Crewman, medically separated for “chronic mechanical low back pain” with a disability rating of 0%.

CI CONTENTION:  His back condition has worsened.  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 - 20040714	VARD - 20041209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical Low Back Pain	5299-5237	0%	Thoracolumbar Strain	5237	20%	20041021	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

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 November-December 2002 time frame without any specific injury or trauma.  He complained of numbness and tingling going down both legs, but radiographic studies done in September 2003 showed no degenerative disc disease.  However, they did show osteophytes at L3, L4, and L5 with a Schmorl’s node at T12-L1.  Electrodiagnostic studies on 11 November 2003 were negative for radiculopathy and a subsequent MRI done on 22 January 2004 showed no evidence of disc herniation or canal stenosis.

At the 19 March 2004 orthopedic clinic appointment, 6 months prior to separation, the CI reported chronic low back pain with occasional radiculopathy.  The condition was aggravated with sitting or standing for long periods of time.  He reported he could no longer do sit-ups and had difficulty lifting things.  On examination, there was mild spinal tenderness to palpation.  During range of motion (ROM) testing the CI could only touch his knees with forward flexion.  It appeared that his right and left lateral flexion was reduced to 15 degrees each (normal 30), but this could be equivocal because the examination did not specify the plane of motion.  There were no other spinal ROM measurements and no report of pain with motion.  Provocative maneuvers used to elicit radicular pain caused LBP instead.  The examiner noted that the CI had normal motor strength, sensation and reflexes.  

During the 29 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the examiner recorded chronic LBP with activities like sit-ups and running.  Physical examination showed decreased ROM due to LBP, but the examiner did not list ROM measurements.  The 30 April 2004 MEB physical therapy ROM study, 4 months prior to separation, showed forward flexion of 35 degrees (normal 90), after repetition, and total combined ROM of the thoracolumbar spine of 120 degrees (normal 240), after repetition.  The examiner noted that flexion, extension and lateral flexion measurements were all limited by pain.  

The 9 June 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of LBP that interfered with the CI’s ability to lift or perform twisting and turning maneuvers.  The CI reported that his LBP was exacerbated by prolonged sitting or standing.  Physical examination showed mild discomfort with palpation of the lumbar para spinal muscles.  There was slightly decreased muscle strength in the lower extremities with flexion and extension movements of both the hips and knees, but this weakness was due to pain.  

At the 21 October 2004 VA Compensation and Pension (C&P) evaluation, 1 month after separation, the CI reported constant 5 out of 10 LBP with radiation down both legs.  The CI reported that he had not missed any work due to his LBP.  Physical examination showed a normal posture and gait.  There was no radiation of pain on movement, no muscle spasm, and no tenderness noted.  The ROM study showed flexion of 60 degrees, limited by pain, and combined thoracolumbar ROM of 210 degrees.  The examiner noted that the ROM measurements were not affected by fatigue, weakness, lack of endurance or incoordination.  Provocative maneuvers to elicit radicular pain, produced pain in the back.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded analogous to 5237 (lumbosacral strain) citing, ROM limited by pain and “no paraspinous tenderness.”  The VA rated the back condition 20%, coded 5237, based on the C&P examination 1 month after separation, citing “limitation of motion with pain.”  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 MEB physical therapy and VA C&P examinations.  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 back condition, coded 5237.  

BOARD FINDINGS:  In the matter of the back condition, the panel unanimously recommends a disability rating of 20%, 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 Mechanical Low Back Pain	5299-5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161009, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180001434, 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