RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01552
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060626

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Combat Engineer, medically separated for “chronic back pain” with a disability rating of 10%.   

CI CONTENTION:  Condition warranted a higher rating on separation.  The CI also 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 - 20060505	VARD - 20061011	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5242	10%	Chronic Lumbar Spine Strain	5237	10%	20061002	
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 chronic back pain condition began in June 2004 after an IED blast in Iraq when the CI was thrown onto the radio mount inside his vehicle.  Treatment included rest, activity modification, and Toradol injections without resolution of the symptoms.  In July 2005, the CI reinjured his back stepping into a pothole and falling on his knees, resulting in constant back pain.  

At the 27 September 2005 primary care clinic appointment, 9 months prior to separation, the CI complained of low back pain with muscle spasm.  Physical examination revealed a normal gait and posture, with no tenderness or spasm.  Thoracolumbar range of motion (ROM) was not complete, but was without pain.  Neurological examination was intact.  

At the physical therapy examination on 19 January 2006, 5 months prior to separation, the CI rated his pain as 6/10.  Physical examination showed flexion at 45 degrees (normal 90) and a combined ROM of 165 degrees (normal 240).  Motion was limited by pain in all planes.  

The 20 January 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, noted complaints of back pain.  Physical examination showed a normal gait, 5/5 motor strength, tenderness, and decreased ROM with pain on all planes.  

The 17 February 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of constant back pain, ranging from dull to sharp to stabbing in nature.  Numbness into his left lower extremity was reported with running, walking, or prolonged sitting.  Treatment included modified activity, medications, and physical therapy; however, the pain continued.  Physical examination showed normal sensation to light touch.  An MRI evaluation of the lumbar spine showed degenerative changes at T12-L1 with no other evidence of back degeneration.  

At the 2 October 2006 VA Compensation and Pension (C&P) evaluation, less than 4 months after separation, the CI reported stiffness and numbness over the lower back when standing or sitting.  Pain was reported as constant, sharp, and elicited by physical activity, with pain intensity reported as 6/10.  No incapacitation was reported.  Physical examination showed normal gait and posture.  Muscle spasms were absent.  Tenderness was noted across the lumbar area.  There was no ankylosis of the lumbar spine.  ROM showed flexion 75 degrees and combined ROM of 185 degrees.  ROM was not limited by weakness and incoordination after repetitive use.  Motor and neurological function were within normal limits.  

The 21 May 2007 C&P examination, 11 months after separation, noted complaints of low back pain and stiffness.  Physical examination demonstrated the CI’s posture and gait were WNL.  There was no evidence of radiating pain on movement or muscle spasm.  Tenderness was present.  ROM was normal.  The joint function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  Neurological examination was intact.  The lumbar spine X‑ray findings were within normal limits.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic back pain condition 10%, analogously coded 5199-5242 (degenerative arthritis of the spine), citing thoracolumbar ROM limited by pain, with localized tenderness.  The VA also rated the chronic back pain condition 10%, analogously coded 5237 (lumbosacral or cervical strain), based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined ROM of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.  

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) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the VA examination 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.  Although there was muscle spasm, it was not 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 the totality of 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 chronic back pain condition.  
BOARD FINDINGS:  In the matter of the chronic back pain condition and IAW VASRD §4.71, 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 20170214, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180009783, 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