RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00503
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20051103

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Calvary Scout, medically separated for “chronic low back pain with degenerative disc disease [DDD] and L4-5 bulge” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 20050727	VARD - 20051125	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain …	5237	10%	Degenerative Disk Disease; Lumbar Spine	5242	20%	20051015	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP)...  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain condition began on 24 June 2004 after a lawn mower he was riding flipped over on him.  Treatment for continued back pain on 8 July 2004 consisted of Skelaxin (metaxalone, a muscle relaxer) and indomethacin (a nonsteroidal anti-inflammatory drug [NSAID]).  At the 27 July 2004 primary care clinic appointment, the CI complained of intermittent pain with tightness and a dull ache.  On examination there was no tenderness, full range of motion (ROM), and negative straight leg raising (to determine nerve root pain).  Medications were changed to naproxen (an NSAID), Lortab (hydrocodone, a narcotic, and acetaminophen, a pain reliever), and Flexeril (cyclobenzaprine, a muscle relaxer).  At a physical therapy (PT) appointment on 29 July 2004, the CI reported LBP with aggravating activity 5/10.  There was no lower extremity radiation, numbness or tingling.  The examiner noted a normal gait with a normal heel/toe walk and no tenderness.  Deep tendon reflex tests (DTRs) were 2+ bilaterally and sensation was intact bilaterally.  Active ROM was within normal limits in all planes of the lumbosacral spine, except “FF (forward flexion) to the mid tibia with decreased rate.”    The examiner’s assessment was LBP with decreased sitting tolerance, and difficulty with forward flexion.  At a PT visit on 26 August 2004 the CI reported “tingling” down the posterior left lower extremity and resolving back pain.  The CI reported a recurrence of LBP on 15 September 2004 and had a positive piriformis test (to detect sciatic nerve irritation by the piriformis muscle).  At a clinic visit on 13 October 2004 the CI reported waxing and waning of the LBP without radiation or bowel or bladder dysfunction.  On examination ROM was full.  

At a 9 March 2005 orthopedics appointment, physical examination revealed a well-developed, well-nourished man in no acute distress who walked, sat and stood well.  The back and legs appeared normal.  There was no redness, swelling, or heat.  There was no atrophy, fasciculation, tenderness nor lumbar paravertebral spasm.  Lumbar lordosis was increased.  Neurologic evaluation was unremarkable.  Heel and toe gait were normal.  ROM measurements were flexion to within 8 inches of the floor calculated to be 70 degrees (normal 90) and extension was calculated to 10 degrees (normal 30).  Lumbar lateral bending was 35 degrees (normal 30) to the left and right; and rotation was 50 degrees (normal 80) to the left and 30 degrees (normal 80) to the right.  During the 8 April 2005 chiropractic clinic appointment, examination showed a pain severity of 2-5/10.  ROM measurements recorded active flexion to 32/65 degrees, extension 5/30 degrees, right lateral flexion 17/25 degrees, and left lateral flexion 17/25 degrees.  An MRI of the lumbar spine dated 25 March 2005 showed DDD and a central mild L4-5 bulge and at L5-S1.  The 24 June 2005 MEB NARSUM examination, 5 months prior to separation, noted complaints of LBP.   The NARSUM physical examination incorporated the findings of the orthopedic physical examination dated 9 March 2005. 

At the 15 October 2005 VA Compensation and Pension (C&P) examination, less than one month before separation, the CI reported chronic LBP described as an ache and a burning and throb which came and went depending on activity.  The CI reported no history of surgeries and no flares of back pain, but the frequency of this pain was daily and constant.  Pain severity was reported as a 4-8/10.  Physical examination showed the CI with a normal gait and posture and no use of assistive devices.  Physical examination showed repetitive motion testing of the lumbar spine was within normal limits.  The lumbar spine showed no active spasm.  ROM measurements in degrees recorded active flexion to 50), normal extension, right lateral flexion 40, normal left lateral flexion, right rotation 50, and left rotation 40 with painful motion.  Straight leg raising was positive on the right at 20 degrees.  Muscle strength in legs and arms was 5/5 and reflexes were 2+ and equal in all extremities with no spasm noted.  While standing on his toes, the CI had increased pain in the back.  When he stood on his heels, pain was slightly increased, and when he put full weight bearing on right leg and [left] leg, the pain did not bother him.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5237 (lumbosacral strain), citing flexion limited to 70 degrees.  The VA rated the back condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing limitation of flexion and pain.  The panel noted that the limitation of thoracolumbar motion recorded in the MEB NARSUM examination met the threshold for a 10% rating.   The PEB noted flexion of 70 degrees with pain which supports the 10% rating.  However, the VA examination proximate to separation was more detailed and reported ROM measurements performed after repetitive motion.  Therefore, the panel placed greater probative value on the VA examination.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees), as reported on the VA examination.  Panel members noted that the chiropractic examination noted a lumbosacral spine flexion of 35 degrees; however, the VASRD requires measurements of the thoracolumbar spine and conversion of lumbosacral to thoracolumbar would be an additional 30 degrees or 65 degrees.  Therefore, panel members relied on the VA measurement as the most precise examination prior to separation.  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 of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the chronic LBP condition, coded 5237.  

BOARD FINDINGS:  In the matter of the chronic LBP condition, the panel recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

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

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180005711, 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