RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01730
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040923

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Chemical Operations Specialist, medically separated for “lumbar degenerative disc disease [DDD], with spinal stenosis” with a disability rating of 10%.  

CI CONTENTION:  Review requested of back injury and an additional condition 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 - 20040816	VARD - 20050208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar DDD, with Spinal Stenosis	5299-5242	10%	Lumbar Spine DDD, L4-5, L5-S1, with Left Lower Extremity Radiculopathy	5010-5242	20%	20041117	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Lumbar DDD, with Spinal Stenosis.  According to the service treatment record and MEB narrative summary (NARSUM), the CI began experiencing insidious low back pain (LBP) in November 2002, and despite medication, physical therapy (PT), manipulation and a single epidural steroid injection, her pain remained.  An MRI in June 2004 revealed lumbosacral DDD as well as a herniated disc impinging on the S1 nerve root.  At the PT clinic on 23 June 2004, 3 months prior to separation, thoracolumbar range of motion (ROM) after repetition was recorded as flexion to 60 degrees (normal 90) with a combined ROM of 185 degrees (normal 240).  Painful motion was present, but there were no comments regarding local tenderness, spams or altered gait.

The 30 July 2004 MEB NARSUM examination, 2 months before separation, noted CI complaints of constant back pain which resulted in an inability to walk more than 2 miles, run, lift over 20 pounds, or stoop/bend.  Physical examination revealed low back spasms and tenderness.  Spinal ROM was documented as flexion to 10 degrees “with pain beyond that,” and extension “with pain past 20,” and right lateral flexion to 25 degrees (normal 30).  

At the 17 November 2004 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant LBP and the inability pursue physical fitness activities that required running, jumping, squatting, crouching or prolonged walking; however, she could manage activities of daily living and drive.  Physical examination revealed a normal gait and posture but spinal tenderness at the lumbosacral junction.  Thoracolumbar ROM showed normal forward flexion and combined ROM of 230 degrees, however, the examiner added that “…repetitive use or pain flare would be expected to reduce forward flexion to approximately 45 degrees with a loss of 10 to 15 degrees in all other planes.” 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing thoracolumbar ROM limited by pain, with spasm, and localized tenderness.  The VA rated the low back condition 20%, dual coded 5010-5242 (arthritis, due to trauma-degenerative arthritis of the spine), based on the C&P examination, citing objective signs of pain throughout all ROM and the examiner’s opinion that repetitive use would reduce flexion by 45 degrees and all other planes by 15 degrees.  Members first agreed that the MEB examination contained minimal and inadequate physical parameters compared to the very detailed and comprehensive VA findings, and therefore, placed the most probative value on the C&P examination.  While a 10% rating was supported for local tenderness not resulting in an abnormal gait, the panel adjudged that VA examiner’s assessment of further limitation of motion after repetition was sufficient for giving benefit to the CI for the next higher rating of 20%.  Additionally, 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 recommends a disability rating of 20% for the low back pain condition, coded 5242. 

BOARD FINDINGS:  In the matter of the lumbar degenerative disc disease, with spinal stenosis, the panel recommends a disability rating of 20%, coded 5242 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

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

CONDITION	VASRD CODE	RATING	
Lumbar Degenerative Disc Disease, with Spinal Stenosis	5242	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160923, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180013151, 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