RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01711
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060428

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

CI CONTENTION:  In addition to the back condition, the CI also requested review of an additional condition 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 - 20060316	VARD - 20061114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Status Post Injury to Thoracic Spine 	5237	20%	20061006	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in February 2004 after a collision with another Soldier.  Thoracic X-rays in May 2005 showed minimal degenerative changes and MRI was unremarkable.  At an orthopedic examination on 21 September 2005, the CI reported persistent right sided back pain increased by deep breathing and use of the right upper extremity.  The MRI was reviewed and asymmetry of the muscles on the right was noted.  Physical examination showed a fullness of the right thoracic paraspinal muscles.  A thoracic CT scan in October 2005 did not identify a soft tissue mass or other abnormality.  There was no surgical indication.

During the 17 November 2005 MEB NARSUM examination, 5 months prior to separation, the CI complained of an inability to run, ruck or lift more than 15 pounds.  Physical examination showed tenderness in the mid-thoracic area, but the CI could forward flex to 80 degrees (normal 90).  Right straight leg raise testing to elicit radicular symptoms was positive at 50 degrees.   The 13 February 2006 physical therapy ROM evaluation for the MEB, 3 months prior to separation, showed flexion of 65 degrees and combined ROM of 215 degrees (normal 240), after repetition.  

At the 6 October 2006 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported waking up with significant pain several times a week and avoided heavy lifting due to pain.  Physical examination showed normal gait and spinal curvatures.  A soft tissue mass was palpable on the right of the thoracic spine measuring 10 centimeters (cm) by 4.5 cm that was non-tender.  The ROM evaluation, after repetition, showed flexion of 65 degrees and combined ROM of 200 degrees with painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbar spine strain), citing tenderness and 70 degrees of painless flexion.  The VA rated the back condition 20%, coded 5237, based on the C&P examination, citing 10% for painful motion of the spine and an additional 10% for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 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 physical therapy and VA 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 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.   

AR20190004099, XXXXXXXXXXXXXXXXXXXX

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Dear XXXXXXXXXXXXXXXXXXXX:

	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.