RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01729
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040319

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Indirect Fire Infantryman, medically separated for “chronic back pain” with a disability rating of 10%.    

CI CONTENTION:  Review requested of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20040126	VARD - 20041122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5239	10%	Spondylolisthesis L5, Recurrent Lumbosacral Strain	5237	10%	20040909	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s chronic back pain began of unknown etiology in October 2002 and progressively worsened, aggravated by strenuous activities and prolonged standing or stretching.  At a physical therapy (PT) evaluation on 21 August 2003, 7 months prior to separation, the CI complained of recurrent low back pain.  Physical examination revealed an anterior pelvic tilt to the spine, with increased lordosis as well as thoracic kyphosis, but there was full, active range of motion (ROM) of the lumbar spine.  In December 2003, an examining neurosurgeon ordered an MRI which showed grade 1 spondylolisthesis at L5-S1.  

The 15 December 2003 MEB PT ROM study, 3 months before separation, showed low back flexion of 90 degrees (normal), with combined a ROM of 225 degrees. The 19 December 2003 MEB NARSUM examination noted CI complaints of constant pain, aggravated by strenuous physical activities, especially bending over.  The provider documented use of a back brace, the ability to heel-toe without difficulty, and no back tenderness.   

At the 9 September 2004 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI described back pain that disturbed his sleep and significantly increased with any bending or lifting.  Prolonged sitting or driving caused him difficulty, and he claimed to no longer be able to run.  He reported being incapacitated for 10 days over the past year due to his pain, and was unemployed, but attending school.  Physical examination of the lumbosacral spine showed a “normal configuration,” with erect posture and steady gait.  The spine exhibited normal curvature and symmetry in appearance during rest and movement.  Measured ROM showed flexion of 82 degrees, and a combined ROM of 195 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic back pain 10%, coded 5239 (spondylolisthesis or segmental instability), citing L5-S1 spondylolisthesis, with combined thoracolumbar ROM of 184 degrees.  The VA also rated the chronic back pain 10%, coded 5237 (lumbosacral strain), based on the C&P examination, citing forward flexion of 82 degrees.  Members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees or combined ROM greater than 120 degrees but not greater than 235 degrees), as reported on the PT and VA examinations proximate to separation.  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 documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all 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 chronic back pain.  

BOARD FINDINGS:  In the matter of the chronic back pain 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 201610 (no day), w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180013026, 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