RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-01092
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20071023

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “vertebral fracture, 5th lumbar vertebra undisplaced” with a disability rating of 0%.

CI CONTENTION:  No specific contention was made.  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 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 - 20071001	VARD - 20080116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Vertebral Fracture, Fifth Lumbar	5235	0%	Residual Fracture, L-5 Vertebral	5235	10%	20071220	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Vertebral Facture at L-5. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in July 2007 when he sustained a fracture at L-5 after a fall. There was minimal loss of vertebral height. The non-displaced fracture was treated with a back brace. The 27 August 2007 MEB NARSUM examination, 2 months prior to separation, noted complaints of low back pain. Physical examination revealed goniometric “lumbosacral” flexion of 35 degrees (normal 90 thoracolumbar) and combined range of motion (ROM) was 165 degrees (normal 240 thoracolumbar).  The examiner noted that all movements were limited by pain.

At the 20 December 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported night-time back pain. There was no impact on activities of daily living nor incapacitating episodes. Physical examination revealed a normal gait and posture, but there was spinal tenderness. Flexion was 85 degrees and combined ROM was 235 degrees with pain. There was no additional loss of ROM following repetitive motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 0%, coded 5235 (vertebral fracture or dislocation), citing VASRD
§4.31 and AR 635-40, paragraph B-15 (zero percent ratings). The VA rated the back condition 10%, coded 5235, based on the C&P examination, citing limitation of flexion or combined ROM. Although the NARSUM’s lumbar flexion measurement was 35 degrees, the panel noted that the examination was only 1 month after injury and that the CI was wearing a back brace during the examination. Therefore, the panel placed higher probative value on the post-separation VA examination. Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees or alternatively for painful motion as noted on both examinations proximate to separation. 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. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the back condition, coded 5235.

BOARD FINDINGS: In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5235 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	
Vertebral Fracture, 5th Lumbar Vertebra Undisplaced	5235	10%	

XXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXX

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.

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