RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01701
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20041216

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Multichannel Transmission Systems Operator/Maintainer, 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 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 - 20041028	VARD - 20050808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lowe Back Pain	5243	10%	Degenerative Disc Disease of the Lumbar Spine 	5243	10%	20050430	
Migraine Headaches	Not Unfitting	Migraine Headaches	8199-8100	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery (lumbar discectomy at L5-S1) to relieve back pain and radiating pain into his left leg.  After surgery he had partial relief of the radiating leg pain, but continued with chronic LBP regardless of pain medication and multiple visits to physical therapy (PT) and the pain clinic.  

At the PT clinic visit on 7 September 2004, 3 months prior to separation, range of motion (ROM) was measured with a goniometer.  After repetition, ROM was flexion of 60 degrees (normal 90) and combined ROM of 185 degrees (normal 240) and was pain limited.  

The 27 September 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic LBP post-surgery with left leg radicular pain mostly resolved with occasional pain down the left leg.  Physical examination showed a well-healed lumbar incision.  Strength was 5/5 (normal) in the lower extremities, intact sensation but paresthesia (tingling) in the left S1 distribution.  The CI had a normal gait and reflexes.  ROM measurements were cited from the above 7 September 2004 PT evaluation.

The 29 September 2004 MRI showed disk extrusion at L1-2 causing impression upon the left thecal sac (prior surgery to L5-S1), L5-S1 with disk bulging, and degenerative changes at L4-5.  The STR documented visits for continued complaints of back pain with use of an electrostimulation device (TENS) and narcotic pain medication.  The CI was on a waiting list for a facet block.  

At the 30 April 2005 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported pain with intermittent numbness and paresthesias (tingling) down his left leg.  His back pain was constant, worse in the morning and night.  Physical examination showed a well healed scar over the lumbar spine from lumber discectomy surgery.  All other back tests were normal and ROM showed flexion of “about 75 degrees” and combined ROM of 230 degrees associated with painful motion.  Radiographic (X-ray) studies of the lumbar spine were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic LBP condition 10%, coded 5243 (intervertebral disc syndrome), citing mild restriction in spinal ROM due to pain, with possible application of AR 635-40.  The VA also rated the chronic lower back pain condition 10%, coded 5243 (intervertebral disc syndrome), citing forward flexion of the thoracolumbar spine 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 MEB/PT examination.    There was no documentation of intervertebral disc syndrome (IVDS) 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 5243.  

Contended PEB Condition:  Migraine Headaches.  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 that 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 LBP condition, the panel unanimously recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  In the matter of the contended migraine headaches 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.  

The panel recommends that the CI’s prior determination be modified as follows, effective the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5243	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161105, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180002671, 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