RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-00738
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve O3, Health Services Administrator, medically separated for “degenerative arthritis of the thoracic lumbar spine” 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 - 20090806	VARD - 20100611	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis of the Thoracic Lumbar Spine	5242	10%	Degenerative Arthritis of the Thoracic Lumbar Spine	5242	0%	20091207	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Degenerative Arthritis of the Thoracic Lumbar Spine.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s degenerative arthritis of the thoracic lumbar spine condition began during basic training in 1986 after the CI pulled a muscle in his mid-back.  After several years of intermittent mild symptoms and minimal interventions, the CI developed low and mid back pain and spasm immediately following an AFPT in 2007.  An MRI in August the same year revealed very minimal bulges in the upper thoracic region and disk desiccation at L5-S1 with 3 mm bulge.  He was released from physical therapy after he reached maximal benefits without full recovery.  A diagnosis of thoracic myofascial pain syndrome and lumbar discogenic pain was made by the spine specialist.  

During the 14 May 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported recurrent back pain and spasms.  Physical examination revealed tenderness from the thoracic to lumbar paraspinal muscles and spasm.  There was full motor strength and straight leg raise test was negative (for radiculopathy).  The 1 June 2009 MEB NARSUM examination, 5 months prior to separation, noted complaints of pain in the mid and low back, responsive to medication, and related to physical activity.  Physical examination showed tenderness over the thoracic and lumbar paraspinal musculature, and presence of spasm.  There was no abnormal curvature of the spine, no muscle atrophy, and motor strength was 5/5 throughout.  Gait was normal.  Straight leg raise test was negative.  Range of motion (ROM) of the thoracolumbar spine documented flexion to 87 degrees (normal 90 degrees) with pain and extension to 24 degrees (normal 30 degrees) with pain.

At the 7 December 2009 VA Compensation and Pension (C&P) examination, 1 week after separation, the CI reported chronic back pain with stiffness, spasm, decreased motion, paresthesia, and numbness.  The examiner found no evidence of radiating pain on movement, weakness, muscle spasm, tenderness, guarding, or signs of radiculopathy.  The spine revealed normal curvature.  ROM recorded flexion to 90 degrees and extension of 30 degrees. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the degenerative arthritis of the thoracic lumbar spine condition 10%, coded 5242 (degenerative arthritis of the spine), citing presence of spasm and tenderness to palpation, to include functional loss IAW VASRD §4.10, §4.40, §4.45, and §4.59.  The VA rated the thoracic lumbar spine condition 0%, coded 5242, based on the C&P examination, citing normal radiographic spine findings, normal ROM, and absence of a diagnosis for the lower back due to no pathology found.

The panel members agreed a 10% rating, and no higher, was justified IAW VASRD §4.59, §4.40 and §4.45 for painful motion with functional loss as adjudicated by the PEB.  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.  The panel noted the condition diagnosed as thoracolumbar myofascial pain syndrome was included in the PEB adjudication, and therefore rated.  Panel members agreed there was not a preponderance of evidence to support that the condition was independent of the primary spine condition, but rather was an integral component of the thoracic lumbar spine condition, and therefore could not be recommended for additional rating IAW VASRD §4.14 (avoidance of pyramiding).  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 thoracic lumbar spine condition.

BOARD FINDINGS:  In the matter of the thoracic lumbar spine condition 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 20170209, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007166, 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