RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01489
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Duty E-5, Military Police Officer, medically separated for “mechanical low back pain” (LBP) with a disability rating of 10%.  

CI CONTENTION:  The CI makes 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 (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 - 20040608	VARD - 20050314	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Low Back Pain	5237	10%	Mechanical Low Back Pain	5299-5237	NSC	20041118	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Mechanical Low Back Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in July 2000 after conducting physical training.  The CI denied any specific injury or trauma.  The first record in evidence for the LBP condition was an emergency room visit dated 4 October 2002.  She reported a 6-month history of LBP.  She was noted to have a full range of motion (ROM) and normal neurological examination.  It was also noted that she was on a profile which limited her activity, but that she pushed past it.  Over the next year the CI was seen on a regular basis and typically noted to have a normal ROM.  

At the MEB NARSUM examination dated 6 March 2004, 6 months prior to separation, the CI reported ongoing LBP, but denied radiation of pain.  The physical examination recorded no tenderness, regional weakness or decrease in sensation or overreaction.  The neurological examination was normal (as documented on the DD 2808 dated 27 January 2004).  Two sets of ROM measurements were documented by physical therapy.  The first was accomplished on 5 March 2004, but was done for the lumbar spine.  The second set, accomplished on 28 April 2004, was for the thoracolumbar spine and recorded a normal flexion at 90 degrees and a combined ROM which exceeded the VA normal value of 240 degrees.  Motion was pain free.  

In primary care on 27 October 2004, 1 month after separation, the CI had normal movement and full ROM.  Radicular symptoms were absent.  At the 18 November 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported mechanical LBP.  The physical examination recorded normal flexion and combined ROM.  Motion was pain free and DeLuca criteria negative.  Gait and posture were normal as was the neurological examination.  Tenderness and spasm were absent.  X-rays of the spine on 18 November 2004 showed mild thoracic scoliosis but otherwise were normal.  

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 to palpation.  The VA determined that the back condition was not service-connected.  The back condition was coded 5299-5237 (lumbosacral strain), based on the C&P examination 2 months after separation.  Although the evidence did not support a 10% rating, the panel agreed IAW DODI 6040.44 the PDBR cannot lower the rating from the PEB.  The mild thoracic scoliosis found on X-ray was consistent with a developmental curvature and was an incidental finding.  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 back condition.  

BOARD FINDINGS:  In the matter of the mechanical low 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, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180001618, 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