RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01501
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070621

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4 , Administrative Specialist, medically separated for “low back pain” with a disability rating of 0%.  

CI CONTENTION:  He is unsure if his records are complete and his back limited his physical activity at time of separation.  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 - 20070313	VARD - 20070703	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	0%	Degenerative Changes Lumbar Spine 	5242	0%	20070425	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s low back pain began in September 2000 without a specific injury.  An MRI on 9 July 2005 showed mild degenerative changes of the lumbar spine and discs without nerve impingement.  In physical therapy on 29 August 2006, 10 months prior to separation, the CI showed full and pain free motion of the lumbosacral spine.  Muscle spasm of the back was noted the next day though.  One month later in physical therapy, the CI showed painful motion, with motion limited by 5 degrees in extension and lateral flexion.  No comment was made regarding rotation.  The neurological examination was intact.  A 31 January 2007 MRI again showed mild degenerative changes of the lumbar spine and discs without nerve impingement.  

During the 26 January 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported lower back pain which was possibly secondary to sports.  Gait and neurological examination were normal.  Atrophy and tenderness were absent.  Formal range of motion (ROM) measurements in physical therapy were performed on 14 February 2007, 4 months prior to separation.  Flexion was limited to 40 degrees (normal 90) by pain and the combined ROM was 155 degrees (normal 240).  The 23 February 2007 MEB NARSUM examination noted that the CI was limited to desk duty.  The examiner referred to the DD Form 2808 physical examination and the ROM from physical therapy.  

At the 25 April 2007 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported that he was unable to sit or stand for long periods of time.  On physical examination, the ROM, gait, and posture were normal as was the neurological examination.  Motion was pain free; tenderness and spasm were absent.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 0%, analogously coded 5299-5237 (lumbosacral strain), citing painful and limited motion.  The VA also rated the low back condition 0%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing full motion without pain.  The evidence showed that at some encounters, including the examination closest to separation, the CI had full and painless motion, while at the ROM measurements for the MEB, motion was limited to 40 degrees for flexion.  The one encounter which supported a 20% rating was an outlier from the other evaluations.  Of the remaining three, two support a 0% rating and the remaining examination supports 10%.  After due deliberation, considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the low back condition, coded 5237, as best representative of the disability proximate to separation  

BOARD FINDINGS:  In the matter of the low back condition, the panel recommends a disability rating of 10%, coded 5237 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	
Chronic Low Back Pain	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170226, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007939, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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. 

Sincerely,					      
Enclosure