RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE: pd-2016-01705
BRANCH OF SERVICE:  army	SEPARATION DATE:  20040415

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

CI CONTENTION:  No specific contention was made.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:

SERVICE PEB - 20040202	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5239	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  The PDBR’s analysis is restricted to the 2004 PEB and medical separation and does not address the CI’s subsequent permanent disability retirement from the United States Army on 25 August 2011.  

Chronic Low Back Pain (LBP).  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s LBP condition began in February 2001 when he fell onto a log during basic training.  His back was reinjured in April 2002 when a vehicle he was driving was rear ended.  X-rays documented bilateral L5 spondylolysis and L5-S1 grade 1 spondylolisthesis, confirmed with MRI which also showed L4-L5 disc protrusion.  A bone scan was negative.  Surgery was not indicated.  The orthopedics evaluation on 9 October 2003, 6 months before separation, noted complaints of LBP with “severe” back pain at least 3 to 4 times per week.  He denied any numbness or tingling, muscle weakness, or bowel or bladder habit changes.  Physical examination revealed no spinal tenderness.  Bilateral lower extremity strength was 5/5, sensation was normal to light touch, and reflexes were symmetrical.  The diagnosis was chronic LBP with no further orthopedic intervention necessary, and the physician recommended an MEB.  

During the 10 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported back pain.  Physical examination revealed tenderness with range of motion (ROM) of flexion to 65 degrees (normal 90).  The 26 November 2003 MEB NARSUM examination, 5 months before separation, noted complaints of chronic LBP.  Physical examination showed lumbosacral tenderness without spasm.  The examiner provided 21 November 2003 MEB PT evaluation results indicating a normal gait, and posture with mild kyphosis (outward curvature at upper back) with forward head and shoulders.  MEB PT ROM showed pain limited motion with flexion of 75 degrees (normal 90) and combined ROM of 190 degrees (normal 240).  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5239 (spondylolisthesis or segmental instability).  The panel 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/or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB and MEB PT examinations; and/or tenderness on the MEB and NARSUM examinations.  In considering other rating options, it was noted that an abnormal spinal contour was present on the MEB PT examination.  Although painful motion was associated with this finding, there was no specification of guarding or spasm.  No other evidence proximate to separation noted an abnormal spinal contour or abnormal gait and the panel concluded that this was not a sufficient basis for a 20% rating (i.e. for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis).  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 concluded there was insufficient cause to recommend a change in the PEB adjudication for the LBP condition.  

BOARD FINDINGS:  In the matter of the LBP condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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 20161108 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180003643, 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. 

	A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure