RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01802
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050705

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

CI CONTENTION:  No specific contention was made.  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 - 20050517	VARD - 20060706	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5242	10%	Lumbar Spine Spondylosis	5239	10%	20060524	
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 progressed since 2002 without any specific injury or trauma, and surgery was not indicated.  Radiographic studies from February 2005 found multilevel disc bulges with mild central canal and L5-S1 bilateral neuroforaminal stenosis (spinal canal narrowing which can cause weakness or numbness in lower extremities). 

The 19 April 2005 MEB NARSUM examination, 3 months prior to separation, noted CI complaints of constant pain which required regular anti-inflammatory medications and caused sleep disturbance.  Physical examination demonstrated spinal tenderness.  Goniometrically measured thoracolumbar range of motion (ROM) was flexion to 90 degrees (normal) with a combined ROM of 235 degrees (normal 240); painful motion was not addressed.

At the 24 May 2006 VA Compensation and Pension (C&P) examination, 11 months after separation, the CI reported pain rated at 5/10, and managed by limiting activity and not exercising; he denied lost time from work.  Physical examination showed normal gait and no spinal tenderness.  Lumbar spine flexion was 85 degrees and combined ROM was 225 degrees, with no ROM decrease or painful motion after repetition. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), citing localized spinal tenderness.  The VA also rated the back condition 10%, coded 5239 (spondylolisthesis or segmental instability), based on the C&P examination, citing subjective complaints of pain.  Members agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees) or spinal tenderness, as recorded on the MEB NARSUM examination most 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.  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 pain condition.  

BOARD FINDINGS:  In the matter of the chronic back pain 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.

AR20180011415, 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.