RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00638
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20060713

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Human Intelligence Collector, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:  The 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 - 20060605	VARD - 20070924	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5241	10%	Status Post L5 S1 Spinal Fusion	5241	10%	20070523	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent an L4-5 lumbar fusion on 4 October 2005.  The 17 May 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of residual sharp, chronic low back pain.  She had no numbness or tingling.  The physical examination showed a range of motion (ROM) of 70 degrees of flexion (normal 90) and 15 degrees of extension (normal 30) with application of Deluca.  There was tenderness and mild muscle spasm.  No radicular symptoms were noted.  

At the 23 May 2007 VA Compensation and Pension (C&P) evaluation, 10 months after separation, the CI reported stiffness, weakness and chronic pain elicited with physical activity.  She also complained of spasms extending to the lower back, middle back and neck.  She denied any incapacitation.  The physical examination showed no radiating pain or muscle spasms.  There was no ankylosis of the spine.  She had a positive straight leg raise test.  Her ROM was 90 degrees of flexion and 30 degrees of extension with pain.  Repetitive use did not produce fatigue, weakness, lack of endurance or incoordination.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5241 (spinal fusion), citing muscle spasm, tenderness and 70 degrees of flexion with resolution of radiculopathy.  The VA rated the back condition 10%, coded 5241 (spinal fusion), based on the C&P examination 10 months after separation, citing flexion greater than 30 degrees but not greater than 60 degrees with a normal gait.  

The panel agreed that a 10% rating was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees.  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.  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 adjudication for the back condition.  

BOARD FINDINGS:  In the matter of the back 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 20170215, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180004722, 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