RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00928
BRANCH OF SERVICE:  arMY 	SEPARATION DATE:  20060222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O3, Intelligence Officer, medically separated for “chronic low back pain” 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 - 20051227	VARD - 20060824	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5239	10%	Degenerative Disc and Joint Disease, Lumbar Spine	5243	0%	20060210	
			Sacroiliitis, Left Lower Extremity	8699-8620	0%		
Subacromial Bursitis, Left Shoulder	Not Unfitting	Left Shoulder Bursitis	5019	0%		
Chondromalacia of Patella on the Left		Retropatellar Pain Syndrome, Left Knee	5299-5014	0%		
Lateral Gutter Impingement, Left Ankle		Left Ankle Lateral Gutter Impingement	5299-5271	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in 2003 and was aggravated in 2005 after heavy lifting.  Radiographic studies in March and May 2005 showed degenerative disc disease (DDD) and degenerative joint disease (DJD) about the lumbosacral spine with slippage of L5 upon S1.  Despite conservative treatment, his back pain continued and he was referred to a MEB.    

During the 29 September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported severe back pain with numbness and tingling extending down the left leg and foot.  His physical examination (PE) showed no limitation of spinal movement and no tenderness was noted.  Painful motion was present.  Straight leg raise test was negative for radiculopathy and the CI had a normal gait.  The 30 October 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of “extreme pain in his lower middle back, numbness and tingling in his left hip and foot, and pain in his ankles and knees.”  The PE noted, “Muscle spasm in the paraspinous muscles bilaterally,” without identifying the affected spinal level.  Straight leg raise and cross straight leg raise tests were negative.  There was normal strength in the lower extremities and sensation was intact to light touch and pinprick.  

At the 10 February 2006 VA Compensation and Pension (C&P) evaluation, 1 month prior to separation, the CI reported daily, 7/10 low back pain extending into the left leg.  His PE revealed a normal gait and posture.  Spinal range of motion (ROM) measurements were normal and remained so after repetitive motion.  There was tenderness in the area of the left sciatic region.  Motor strength and reflexes in the lower extremities were normal.       

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 10%, coded 5239 (spondylolisthesis), citing ROM measurements and positive spasm.  The VA rated the back condition at 0%, coded 5243 (intervertebral disc syndrome), the month of separation, citing a full and painless ROM.  Although there was insufficient limitation of motion to support a 10% rating, the panel agreed a 10% rating was justified for the presence of painful motion, tenderness and or spasms as indicated in the pre-separation examinations.  There was no degree of muscle spasms 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 that there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain condition.  

Contended PEB Conditions:  Subacromial Bursitis, Left Shoulder, Chondromalacia of Patella on the Left, and Lateral Gutter Impingement, Left Ankle.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Although the conditions were profiled, none of them were implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at or near separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.   

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended subacromial bursitis, left shoulder, chondromalacia of patella on the left, and lateral gutter impingement, left ankle conditions; the panel unanimously 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 Treatment Record 

AR20180004881, 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