RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00502
BRANCH OF SERVICE:  ArMY 	SEPARATION DATE:  20090427

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Cavalry Scout, medically separated for “degenerative disc disease, lumbar spine” with a disability rating of 10%.   

CI CONTENTION:  A review of the lumbar spine, left knee, and thoracolumbar spine pain, along with migraines and bilateral pes planus conditions was requested.  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 - 20090116	VARD - 20090622	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Spine DDD 	5242	10%	Thoracolumbar Strain	5242	10%	20090402	
			Postoperative Back Scar	7801	0%		
Headache	Not Unfitting	Intermittent Headaches	8100	0%		
Left Knee Pain		Left Knee Patellofemoral Pain Syndrome	5299-5261	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Lumbar Spine Degenerative Disc Disease (DDD).  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s condition began in February 2006 during the military training phase with no acute episode such as a fall or lifting injury.  Pain was persistent in the right hip with right-sided paresthesias, but not in the back.  An MRI on 19 March 2007 revealed disc disease at L4-L5 and L5-S1 with a large disc extrusion which migrated both superiorly and inferiorly.  On 31 March 2008 the CI reported the back pain interfered with sleep and he had radiating pain in the right posterior leg and foot with occasional numbness/tingling in the foot.  Treatment consisted of celecoxib (a nonsteroidal anti-inflammatory drug) and tramadol (an opioid-like medication) and he was referred for chiropractic care.  An MRI dated 15 May 2008 demonstrated a large right para-midline L-5 S-1 disk protrusion which severely narrowed the right lateral recess and exerted impressive mass effect on the right S1 nerve.  Despite physical therapy and chiropractic care, the lower back pain continued radiating to the legs when walking and was worse on the right.  The CI underwent a lumbar discectomy at L5-S1 on 21 August 2008. 

At an orthopedic clinic appointment on 16 September 2008, 7 months prior to separation, the CI reported his pain was much improved, back pain was minimal; and there was no radiating pain to the legs.  Physical examination showed tenderness of the lumbosacral spine and spasms of the paraspinal muscles.  No range of motion (ROM) measurements or gait abnormalities were reported.  At an orthopedic clinic appointment on 12 November 2008, the CI reported unrelenting pain.  Physical examination showed lumbosacral pain elicited by motion, but no ROMs were reported.  The CI was determined not to be a candidate for further surgery. 

The 22 December 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of low back pain.  The CI used no medication or assistive devices.  Physical examination showed normal strength and reflexes, and no spasms, guarding, sensory loss or atrophy in the lower extremities.  Gait was normal and there was no abnormal spine posture or curvature.  There was tenderness in the paraspinal area in the lower lumbar spine.  ROM measurements after repetition showed a flexion of 70, 72, 75 degrees (normal 90) and a combined ROM of 170 degrees (normal 240).  A straight leg raise test was negative for radiculopathy.

At the 2 April 2009 VA Compensation and Pension (C&P) examination, one month before separation, the CI reported back pain rated 8/10.  Physical examination showed a normal posture and gait.  There was tenderness of the lower back and the CI had full ROM with pain at the end of all motions except left rotation.  Reflexes were normal and sensation was intact.    

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), citing tenderness and limitation of motion.  The VA also rated the back condition 10%, coded 5242, based on the C&P examination, citing painful motion and DDD.  

The panel agreed a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and a combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB NARSUM 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 lumbar spine DDD condition.  
 
Contended PEB Conditions:  Headache and Left Knee Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions were profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions so no additional disability ratings are recommended.   

BOARD FINDINGS:  In the matter of the lumbar spine DDD condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended headache and left knee pain conditions, the panel recommends no change from the PEB determinations as not unfitting.  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 20170213, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180005710, 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