RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00046
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040113

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

CI CONTENTION:  Her condition continues to worsen.  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 - 20031209	VARD - 20040511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5235	10%	Compression Fracture	5235	10%	20040310	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s chronic low back condition began in July 2003 after she jumped off a cargo net during basic training and sustained an injury to her lower back.  X-ray showed a burst fracture with compression and approximately 50% loss in height at L-1.  She then went on three months of convalescent leave in a brace, remaining neurologically intact throughout this time.  She began physical therapy (PT) approximately 12 weeks post injury; which did not alleviate her symptoms to the level where she could successfully complete the physical requirements of training.  

The 29 October 2003 PT examination, 3 months prior to separation, noted low back pain at rest that increased with lifting, sweeping, sitting crossed legged, and standing greater than 2 hours.  Physical examination showed flexion, extension, and side bending (bilaterally) within normal limits.  Rotation (bilaterally) was decreased by 20%.  Painful motion was noted with extension, left side bending, and right rotation.  Gait was normal and the CI could squat normally.  

The 7 November MEB NARSUM examination, 2 months prior to separation, noted complaints of low back pain which prevented the CI from running and became limiting if she walked greater than a mile.  Physical examination showed a normal gait.  Range of motion (ROM) measurements by PT on 1 December 2003 showed normal forward flexion and 235 degrees combined ROM (normal 240), all after three repetitions.  The spinal contour showed no deformity.  The CI did have localized tenderness around the L1 region with some mild paravertebral muscle spasm.  

At the 15 March 2004 VA Compensation and Pension (C&P) examination of the spine, 2 months after separation, the CI reported she could complete her stretches and had no radicular symptoms.  She could not lay supine for any extended time and had difficulty arching her back.  She could no longer perform gymnastics.  Rain, cold, or snowy weather made her symptoms worse.  She noted her back did not interfere with her work at that time (she worked in advertising for a radio station).  The examiner found a stable gait without any assistive device in use. The CI also did not wear a back brace.  Spinal alignment was good.  She did show tenderness over the upper lumbosacral posterior spinous process in the region of L1, while there were no palpable spasms and the CI denied any tenderness otherwise.  ROM measurements were all normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5235 (vertebral fracture or dislocation), citing mild para spinous muscle spasm and tenderness and no radiculopathy, altered gait, or significant loss of spinal ROM.  The VA also rated the back condition 10%, coded 5235, based on the C&P examination, citing localized tenderness not resulting in abnormal gait or abnormal spinal contour, with no ratable ROM deficit.  

The panel agreed a 10% rating was justified for decrease in combined ROM, the presence of painful motion, tenderness, and spasm.  There was also presence of vertebral body fracture with loss of 50 percent or more of the height, which supports a 10% rating.  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 low back pain.  

BOARD FINDINGS:  In the matter of the chronic low back pain and IAW VASRD §4.71, 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 20170116, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR, 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