RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01579
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041020

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

CI CONTENTION:  “Review all conditions.”  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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20040624	VARD - 20050214	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5235-5237	10%	Degenerative Disc Disease Lumbar Spine	5235-5237	20%	20040928	
Cervical Spine Pain	Not Unfitting	Cervical Spine Injury	5299-5237	NSC		
Right Shoulder Pain		Right Shoulder Injury	5201			
Right Wrist Pain		Right Wrist Injury	5215			
Right Hip Pain		Right Hip Greater Trochanteric Bursitis	5252-5019	0%		
Anxiety Disorder		Adjustment Disorder with Mixed, Anxious and Depressed Mood	9440	10%	20040914	
Adjustment Disorder						
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in 1998 while in basic training and worsened after two pregnancies.  At a primary care visit on 17 June 2003, the CI reported back pain aggravated by the move to her new duty station.  Physical examination showed full range of motion (ROM), no tenderness and a negative straight leg raise test for radiculopathy.  A 28 June 2003 MRI showed degenerative disc disease at L3-4 and L4-5, without disk herniation.  X-rays on 10 September 2003 showed an avulsion fracture of the anterior and superior endplate of L-4 and mild degenerative changes of L-3, L-4 and L-5.    

At an orthopedic appointment on 10 September 2003, the CI reported a 5-year history of chronic, non-traumatic low back pain with no radicular symptoms.  Physical examination revealed tenderness over the L-4/L-5 paraspinal muscles and bilateral sacroiliac joints, but no deformity, erythema or discoloration.  The examiner reported decreased ROM; however, no measurements were reported.  There was pain with flexion, full extension and left lateral bending.  

At a primary care visit on 29 September 2003, 13 months before separation, the CI complained of steady LBP for the past 3 years.  She reported that since the birth of her children in 2000 and 2001, the pain had been constant over the lower spine, with radiation along the right sciatic distribution to the right knee.  There were no documented ROM measurements or duty restrictions.  The examiner assessed “lower back pain with sensitive back muscles for L2-5,” and recommended a temporary profile for 90 days with physical therapy.

At a physical medicine consult for the MEB on 10 December 2003, the physician reported, “The only thing I could find is that the patient has a mild posterior iliac crest syndrome and some mild trochanteric bursitis.  Based on these findings, the patient is still fit for duty.”  The 7 January 2004 MEB consultation, 10 months prior to separation, noted CI complaints of LBP with no numbness, weakness or tingling.  Physical examination showed pain with forward flexion, however, no ROM measurements were documented.  Straight leg raise testing was negative for radiculopathy with normal strength in the lower extremities.  Sensation was intact bilaterally and reflexes were normal.  The CI’s gait and heel-toe walking were normal. The 31 March 2004 MEB NARSUM examination, 7 months before separation, noted complaints of LBP extending down the back of the leg.  The examiner repeated the 7 January 2004 MEB physical examination findings.
 
At the 28 September 2004 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported that the onset of LBP in 1999 came gradually and worsened during her pregnancies.  Physical examination showed a normal gait, no lumbar or paraspinal tenderness or spasm, and no abnormal curvature of the spine.  ROM measurements showed flexion to 45 degrees (normal 90) and a combined ROM of 145 degrees (normal 240).  Repetitive testing increased the pain without decreasing ROM measurements.  Lower extremity reflexes and strength were normal.      

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5235-5237 (vertebral fracture-lumbosacral strain), citing no muscle spasm, but tenderness in the paraspinous area.  The VA rated the back condition 20%, also coded 5235-5237, citing objective findings of thoracolumbar forward flexion greater than 30 degrees but not greater than 60 degrees shown during the pre-discharge examination.  Members noted the only service ROM measurement was from the 17 June 2003 primary care examination, which documented full ROM, but was more than a year before separation.  The C&P evaluation, provided ROM measurements 1 month before separation, and therefore, carried the most probative value.  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 chronic LBP condition, coded 5235-5237.  

Contended PEB Conditions:  Cervical Spine Pain, Right Shoulder Pain, Right Wrist Pain, Right Hip Pain, Anxiety Disorder and Adjustment Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled prior to the MEB NARSUM examination and none of the conditions were judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic LBP condition, the panel unanimously recommends a disability rating of 20%, coded 5235-5237 IAW VASRD §4.71a.  In the matter of the contended cervical spine pain, right shoulder pain, right wrist pain, right hip pain, anxiety disorder and adjustment disorder conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  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	5235-5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161022, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180001852, 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