RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00938
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050515

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

CI CONTENTION: “Constant back pain, limited movement, sporadic numbness/tingle in arms/legs...”  The CI also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  

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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20050408	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain, Secondary to Degenerative Disc Disease…	5299-5242	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

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 2004 after being thrown to the side of the gun turret of his vehicle which was involved in an accident.  

During the 2 November 2004 primary care appointment, 6 months prior to separation, the CI complained of low back pain that at times radiated across and up his back.  The examiner stated the CI had “full range of motion (ROM)” with pain.  

At the time of the 21 December 2004 orthopedic examination, 5 months prior to separation, the CI complained of lower back pain.  Physical examination revealed a normal gait and spine appearance with no tenderness or muscle spasms.  “Normal” ROM measurements for flexion, extension, left/right rotation and left/right lateral flexion.  According to the NARSUM, thoracolumbar ROM measurements performed by physical therapy (PT) on 22 February 2005, 3 months prior to separation, showed flexion of 50 degrees (normal 90) and combined ROM of 170 degrees (normal 240) after repetition.  

The 22 March 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of mid and low back pain.  Physical examination showed mild to moderate tenderness at the L1-2 level with minimal tenderness in the L2-4 levels and moderate tenderness at L4 to S1 levels.  There was also tenderness at the left paraspinal muscles in the lower back.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing thoracolumbar ROM limited by pain.  The panel noted the PT documentation of lumbar flexion of 50 degrees which met criteria for a 20% rating; however, the preponderance of STR evidenced normal but painful motion.  Panel members agreed that the evidence supports a 10% rating for the presence of painful motion and tenderness.  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 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 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.  

AR20190007525, 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.