RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01734
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20060416

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Armament Systems Mechanic, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:  He should get a disability retirement for his back with not less than a 40% rating.  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 - 20060214	VARD - 20060724	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Degenerative Intervertebral Disk Disease of the Lumbar Spine	5243	40%	20060608	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s chronic low back pain condition began in May 2002 after another soldier fell on his back.   Treatment consisted of anti-inflammatory medications and muscle relaxers.  An MRI dated 24 November 2004 demonstrated minimal straightening of the lumbar lordosis with mild degenerative disc disease from L4 to S1 including an annulus tear at L4-L5 and minimal midline disc protrusion at L5-S1 contained in the epidural space.  The CI was seen in December 2004 for pain management.  Lumbar epidural steroid injections under video fluoroscopic guidance directed to the right L5-S1 levels were recommended.  Injections were given on 23 December 2004 and 3 January 2005.  Pain worsened when doing crunches in May 2005.  A 24 May 2005 MRI showed a tiny disc protrusion in the right L3-4 neural foramen with abutting of the right L3 exiting nerve root against the facet.  The right L3-4 neural foramen was moderately narrowed or slightly greater, secondary to the disc herniation.  Mild neural foraminal narrowing was present at the left L4 to S1 and right L4-5 secondary to underlying bulging discs.  There were also minimal degenerative changes L4 to S1 with underlying straightening of the lumbar lordosis and a punctate annulus tear at L4-5 and tiny midline disc protrusion at L5-S1.  The CI returned for pain management on 25 May 2005 where he reported significant pain improvement after three injections.  Neurontin (gabapentin for nerve pain) was prescribed.   An additional epidural steroid injection was given in June 2005.  At the 14 June 2005 primary care clinic visit, 10 months prior to separation, the examiner noted “full range of motion” (ROM) in all planes with no pain as well as a normal gait and spine curvature.  At a primary care clinic appointment on 15 July 2005 the CI complained of back pain that radiated into his legs and a sensation of intermittent right foot drop.  The CI had a positive right straight leg raise (SLR) test (to determine nerve root irritation), raising the possibility of an L5 radiculopathy/sciatica.  Another epidural steroid injection was given in July 2005, followed up with right lumbar facet medial branch blocks at L3-L4, L4-5, and L5-S1 in August and September 2005.  

During the 23 September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported lower back problems resulting in numbness down the right leg.  Physical examination showed tenderness of the lumbar spine, pain with forward flexion at 70 degrees, and positive SLRs bilaterally.  Right sacroiliac injections were given in October and November 2005.  Despite pain resolution or diminution, the pain returned.  The 30 November 2005 MEB NARSUM examination, 5 months prior to separation, noted complaints of back pain on a daily basis.  Physical examination showed tenderness along the paraspinal lumbar area with “worsened pain on forward flexion at 70 degrees.”  He had positive SLR tests at 45 degrees bilaterally and right sided sacroiliac joint tenderness.  Extension, rotation, and side bending of his back did not exacerbate the pain, but the ROM was limited slightly.  Lower extremity muscle strength was normal.  The examiner noted that in 2005 the CI was evaluated by a spine surgeon whose assessment was that his back was a “non-surgical issue and surgery could only make the condition worse.”  Radiofrequency denervation of the right sacroiliac joint was performed in December 2005.  At the MEB physical therapy clinic appointment performed on 4 January 2006, 3 months prior to separation, active thoracolumbar ROM was flexion 90 degrees (normal 90) and the combined ROM was 210 degrees (normal 240).  

At the 8 June 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported low back pain which radiated to his right leg and flared up “about every 2 to 3 days.” He did not use any assistive devices and was able to walk more than a city block.  Over the prior year, he had one total incapacitating episode, which persisted for over a day.  Physical examination showed the CI "disrobes easily, gets on & off examining table easily...turns from side to side easily."  There were no gross deformities of the lumbar spine and no evidence of muscle guarding or spasms.  He had tenderness of the lower lumbar spine and the right sacroiliac area.  The examiner recorded active flexion to 30 degrees and combined ROM of 130 degrees.  Straight leg raising carried to 60 degrees on the left and 40 degrees on the right with back and leg pain.  The CI had S1 dermatome hypoesthesia (decreased sensitivity) of the right lower extremity.  There was no motor deficiency of either lower extremity and no difficulty conducting “toe and heel walks.”  Repetitive flexion and extension activity showed no change in ROM, pain, weakness, or fatigability.  X-rays of the lumbosacral spine were normal except for some very minimal osteophyte formations seen at L4 and L5.  At a VA clinic visit on 15 February 2007, 10 months after separation, the CI complained of low back pain with almost all movements painful, which was exacerbated over the prior 4 days, possibly due to using a snow blower.  At a VA primary care clinic visit the next day the CI noted a history of “back pain with 3 herniated discs and bilateral leg radiculopathy with right foot drop.”  Examination showed limited ROM of the thoracolumbar spine, positive straight leg raising on the right, and deep tendon reflexes 2+ bilaterally.  He walked with a “normal gait and no foot drop [was] noted.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back condition 10%, coded 5299-5237 (lumbosacral strain), citing tenderness in the lumbar area with worsened pain on forward flexion at 70 degrees.  The VA rated the chronic low back condition 40%, coded 5243 (intervertebral disc syndrome), based on the C&P examination, citing the ROM of forward flexion was 30 degrees.  There was no evidence of further limitation due to loss of motion, incoordination, weakness, flare-ups or lack of endurance due to repeated motion.  There was no evidence of any muscle guarding, spasm, or tenderness of the lumbar spine.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB PT examination 3 months prior to separation.  The panel noted that the limitation of lumbar flexion of 30 degrees reported in the C&P examination suggested consideration of the higher rating of 40%; however, in assigning probative value to these somewhat conflicting examinations, the panel noted that the MEB PT measurements were consistent with other proximate (pre-separation) examinations by primary care and the MEB NARSUM examination.  There was no evidence of an injury or accident in the STR or VA record to explain the marked limitation of motion compared to prior examinations, although the CI was no longer receiving pain management treatments with epidural or facet injections or radiofrequency ablation.  Panel members also noted that the examiner indicated the CI disrobed easily and got on and off the table easily, which is inconsistent with the measured flexion of 30 degrees.  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 (IVDS) with incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months which would provide for a higher rating under that formula (for IVDS).  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 adjudication for the chronic low back condition.  

BOARD FINDINGS:  In the matter of the chronic low 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 20170322, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180008172, 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.

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX

Sincerely,					      
Enclosure