RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01743
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041001

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve CW4, Military Personnel Technician, 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 that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040811	VARD - 20050405	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5242	10%	Degenerative Disk Disease, Lumbar Spine	5243	10%	20050131	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began between 1968 and 1970 during his days as a paratrooper.  In 1999, he reinjured his back in a motor vehicle accident.  A subsequent MRI revealed a disc bulge at L4-5 and a disc herniation at L5-S1.  The CI was not a surgical candidate.  Spinal measurements obtained on 19 February 2004, 7 months prior to separation, revealed normal forward flexion as well as bilateral rotation.  Thoracolumbar extension was measured at 15 degrees (normal 30) and lateral flexion to the right was 20 degrees and to the left was 15 degrees (normal 30 degrees each direction).  The combined range of motion (ROM) was 200 degrees (normal 240).  

An orthopedic examination performed on 23 March 2004, 6 months prior to separation and a day before the MEB NARSUM examination, documented normal spinal ROM in all directions except decreased extension at 15 degrees left rotation at 25 degrees.  The combined ROM was 220.  The 24 March 2004 MEB NARSUM examination noted complaints of constant LBP. The physical examination (PE) revealed the same spinal ROM measurements as documented at the previous days’ orthopedic examination.  There was no documentation of spinal tenderness or a gait description.  His pain rating was assessed as “moderate” and “constant.”  Under the heading of “Present Condition and Current Functional Status” the examiner documented that the CI could “…only stand fifteen minutes before he must sit down.  He has marked pain when changing from a sitting to a standing position.”

At the 31 January 2005 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported continued back pain 10 times per day for a period of 3 hours.  He also endorsed back pain extending to his neck, shoulders, fingers, and knees.  He characterized his pain as aching/sharp and worsened with physical activity.  His PE revealed spinal ROM measurements of normal flexion with pain onset at 20 degrees, extension of 10 degrees with pain onset at 2 degrees, and bilateral lateral flexion and bilateral rotation of 20 degrees with pain onset at 10 degrees.  ROM was additionally limited by fatigue, weakness, and lack of endurance.  Pain had the major functional impact.  The examiner noted that the effect of the CI’s condition on daily activities was inability to walk and stand for extended periods of time.  A primary care encounter document dated 8 January 2004, 4 months after separation, did not numerically document spinal ROM, but rather noted the lower spine was “somewhat limited (flexion)”.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing combined ROM. The VA rated the LBP condition 10%, coded 5243 (intervertebral disc syndrome), based upon the C&P examination 3 months after separation, citing forward flexion of the spine greater than 60 degrees but not greater than 85 degrees.  Panel members extensively deliberated the various descriptions and ranges of spinal motion near the time of separation and agreed that painful motion was present to support at least a 10% impairment rating.  Panel members then considered the clear documentation at the VA examination of pain at 20 degrees of forward flexion as well as pain at 2 degrees of extension despite having an active range to 90 and 10 degrees, respectively.  Such evidence of pain at 20 degrees would warrant a 40% rating under the VASRD; however, this numerical notation of whence pain began was a stand-alone finding that was never replicated in the STR and was inconsistent with prior records contained in the case file.  Panel members agreed that the pre-separation examinations were more probative and consistent with the totality of evidence for the consideration of an impairment rating.  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’s adjudication for the LBP condition.

BOARD FINDINGS:  In the matter of the LBP condition and IAW VASRD §4.71a, the panel unanimously 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 20161111, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180003332, 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