RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01586
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040715

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

CI CONTENTION:  “Extended periods of debilitating pain, depression and PTSD.”  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 - 20040605	VARD - 20041110	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Episodic Low Back Pain	5299-5237	10%	Herniated Nucleus Pulposus L5-S1 with Right Degenerative Disc Disease with Radiculopathy Ending into the Right Lower Extremity to the Level of the Right Knee	5242	10%	20040721	
Depression, Resolved	Not Unfitting 	PTSD with Major Depressive Disorder	9411-9434	10%	20040721	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Episodic Low Back Pain (LBP).  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in April 2001 after a motor vehicle accident.  He underwent surgery in September 2001 and recovered post-operatively without pain.  The CI deployed in May 2003, and in September 2003 he fell backwards out of a 5-ton truck onto his buttocks.  He experienced immediate LBP with numbness down the posterior aspect of his right leg.  During an 8 April 2004 orthopedic consult, 3 months prior to separation, physical examination showed no muscle spasms and normal strength.  The CI was able to heel-toe walk without difficulty and could forward flex with his fingers approximately 6 inches from the floor.  

During the 12 April 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported intermittent numbness and tingling down both legs.  Physical examination revealed normal strength and reflexes, but decreased sensation along the left and right lateral calf.  Straight leg raising testing was positive on the right at 70 degrees.  Lumbosacral spine range of motion (ROM) was flexion of 58 degrees (normal 90) with pain at 40 degrees and a combined ROM of 205 degrees (normal 240).  Repeated measurements showed flexion of 55 degrees with pain at 45 degrees.  

The 30 April 2004 MEB NARSUM examination, 3 months prior to separation, noted CI complaints of daily pain rated at 3-4/10.  Pain was described as a “constant soreness in his back and a cramping pain” that went down the posterior aspect of his right thigh.  The examiner referred to an April 2004 MRI which showed degenerative disc disease at L4-L5 and postoperative changes at L4-L5.  A new disc herniation at L5-S1 on the right side was also noted.  While the examiner referred to the DD Form 2808 for the physical examination, ROM was measured, and after three repetitions, showed flexion of 55 degrees and a combined ROM of 205 degrees with painful motion.  Prognosis was estimated as stable.  

At the 21 July 2004 VA Compensation and Pension (C&P) evaluation, 1 week after separation, the CI reported persistent, daily that waxed and waned into the right lower extremity and down to the knee.  He was able to sit for 1-3 hours until pain increased, and stand for up to 40 minutes before he needed to move; rest helped relieve pain.  Physical examination of the lumbosacral spine showed “some loss with a normal lordosis curve,” and there was tenderness along the paraspinous musculature from L4-S1 bilaterally.  The CI was able to heel-toe walk without difficulty, and the examiner stated the CI walked “normally,” did not need assistive devices, and had no trouble arising from the chair or changing positions.  ROM testing showed flexion of 70 degrees and a combined ROM of 210 degrees.  There was no loss of motion, pain on movement or incoordination upon repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5299-5237 (lumbar spine strain), citing tenderness and the CI’s ability to forward flex with hands 6 inches from the floor.  The VA rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 1 week after separation, citing the 10% criteria under the general spine rating formula.  In determining the probative values of examinations proximate to separation, the panel noted that the NARSUM ROM was lumbosacral and not thoracolumbar as specified by the VASRD (§4.71a, Plate V). Goniometric measurements were not taken at the orthopedic examination, but indicated greater than 60 degrees of thoracolumbar flexion based on fingertip distance from the floor.  The C&P evaluation proximate to separation (6 days after separation) noted flexion of 70 degrees and a combined ROM of 210 degrees and was compliant with all VASRD rating guidelines.  Therefore, the panel placed a greater probative value on this examination, and agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees).  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the low back pain condition.  

Contended PEB Condition:  History of Depression, Resolved.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic episodic low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended depression condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  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 20161007, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180001875, 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