RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01620
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040417

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E5, Food Service Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:  The CI made 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, 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 it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

SERVICE PEB - 20040217	VARD - 20040927	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Degenerative Joint Disease, Lumbar Spine 	5242	20%	20040826	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began in March 2003 after heavy lifting.  She complained of 10/10 back pain.  On examination, there was tenderness and muscle spasms, but her gait was “stable.”  

At the 4 December 2003 Troop Medical Clinic appointment the examiner recorded full range of motion (ROM) with complaints of moderate pain and bilateral paraspinal muscle tenderness.  Thoracolumbar ROM measurements performed by PT on 22 December 2003 (4 months prior to separation) showed flexion of 45 degrees (normal 90) and combined ROM of 140 degrees (normal 240).  Tenderness, muscle spasm and gait were not addressed.  The 5 January 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, showed tenderness.  The 7 January 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of constant low back pain.  Physical examination showed some spinal tenderness.  ROM testing showed lumbar flexion of 45 degrees and combined ROM of 140 degrees.

At the 26 August 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported constant but varying back pain which was aggravated by bending and lifting and prolonged sitting or standing.  Physical examination showed a slow but otherwise satisfactory gait pattern.  She was able to stand erect and there were no muscle spasms, but she did have tenderness.  Thoracolumbar ROM measurements recorded active flexion to 50 degrees and combined ROM of 155 degrees, with pain on extremes of motion.  There was no additional limitation of motion after repetitive motion.  

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 a combined ROM of 140 degrees.  The VA rated the lumbar spine condition 20%, coded 5242, (degenerative arthritis of the spine), citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.  

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 NARSUM and VA 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 chronic low back condition, coded 5237.  

BOARD FINDINGS:  In the matter of the chronic low back condition, the panel unanimously recommends a disability rating of 20%, coded 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 Low Back Pain 	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161006, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180002563, 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