RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01095
BRANCH OF SERVICE:  army	SEPARATION DATE:  20060923

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

CI CONTENTION:  The CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 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 - 20060811	VARD - 20071019	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	10%	Residual Low Back Injury Post Compression Fracture T12 with Right Sciatica	5235	10%	20040202	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Chronic Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in August 2005 when he fell from a truck sustaining a hyperextended back injury.  Both initial and remote lumbar spine X-rays revealed bulging and degenerative disc disease and a bony 12th thoracic vertebra irregularity.  A neurosurgical evaluation deemed the CI was not a surgical candidate.  Despite conservative treatment the CI’s back pain continued and he did not return to full duty.

A pain management evaluation on 9 May 2006, 4 months before separation, revealed “normal” thoracolumbar spine range of motion (ROM).  At the 6 June 2006 MEB examination recorded on DD Form 2808, 3 months prior to separation, the CI reported having trouble sleeping due to back pain and right leg numbness.  Physical examination revealed spinal tenderness and thoracolumbar spine painful motion.  The 9 June 2006 MEB NARSUM examination noted complaints of constant back pain which was exacerbated by running, bending, lifting, and sitting for prolonged periods.  Physical examination noted spinal tenderness.  Thoracolumbar ROM was flexion to 80 degrees (normal 90) and combined ROM was incomplete; painful motion was present.  Peripheral neurologic findings were normal.

At the 6 February 2007 VA Compensation and Pension (C&P) general examination, 4 months after separation, the CI reported right lower extremity numbness.  He had problems lifting, carrying, and reaching due to back pain.  No incapacitating episodes were noted.  Physical examination revealed a normal gait, posture, and spinal contour.  Spinal muscle spasms were not present and peripheral neurologic testing was normal.  ROM was flexion to 75 degrees which decreased to 60 degrees with repetitive use.  The combined ROM was 175 degrees (normal 240); painful motion was present.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing tenderness.  The VA also rated the back condition 10%, coded 5235 (vertebral fracture or dislocation), based on the C&P examination, citing limitation of flexion.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees); based on the totality of the STR ROM examinations.  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 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’s 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.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007239, 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