RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01573
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040506

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Medical Logistics Specialist, medically separated for “chronic low back pain and sacroiliac dysfunction” with a disability rating of 10%.  

CI CONTENTION:  Back and neck pain have progressed and sexual trauma was not disclosed prior to separation.  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 FPEB - 20040126	VARD - 20040213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain… 	5237	10%	Lumbar Strain	5237	20%	20040213	
	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in early 1998 after she was in a motor vehicle accident.  In March 1998, initial X-rays were normal.  In October 1998, the CI reported being kicked in the back and was told she sustained an L1 vertebra fracture; however, no record of this was found in STR entries.  Two days after the reported back injury, the CI was diagnosed with soft tissue damage.  A 4 January 1999 treatment note recorded an L1 process fracture but X-rays the same day were normal.  September 2001 X-rays and an October 2001 bone scan were also normal.  A 4 June 2003 physical therapy range of motion (ROM) examination noted, in degrees:  flexion to 85 (normal 90), extension to 15 (normal 30), right and left lateral flexion to 20 and 25 (normal 30), right rotation to 20 (normal 30), and left rotation to 30.  
At the 18 August 2003 MEB NARSUM examination, 9 months before separation, the CI complained of low back pain and an inability to perform military duties. Physical examination revealed generalized lumbosacral tenderness with distal neurovascular, sensory, and strength components intact and normal.  Back ROM was listed as “within normal limits.”  

At the 13 February 2004 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported constant low back pain described as “crushing, aching, sticking, and sharp.”  It was aggravated by physical activity and impaired her ability to lift and carry objects.    Physical examination revealed a normal gait and mild lumbar tenderness, but no muscle spasm or pain radiation.  ROM was painful and, in degrees, was:  flexion to 40, extension to 20, bilateral lateral flexion to 20, and bilateral rotation to 30, with a combined ROM of 160.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 10%, coded 5237 (lumbosacral strain), citing normal X-rays, no focal neurological deficits, and tenderness present.  The VA rated the back condition 20%, also coded 5237, based on the C&P examination 3 months after separation, citing thoracolumbar spinal flexion greater than 30 degrees but not greater than 60 degrees.  The panel majority 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 most proximate to separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the chronic low back pain condition, coded 5237.   

BOARD FINDINGS:  In the matter of the chronic low back pain condition, the panel majority recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161020, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180001836, 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