RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01931
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070124

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Trainee, medically separated for “low back pain” with a disability rating of 10%.  

CI CONTENTION:  In addition to reviewing her back and hip conditions, 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 - 20070108	VARD - 20070808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain 	5237	10%	Lumbar Strain	5237	10%	20070228	
Right Greater Trochanteric Bursitis	Not Unfitting	Right Hip Bursitis	5019	10%	20070228	
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 September 2006 after participating in physical activities and road marching.  X-rays were unremarkable and she was not a surgical candidate.  The 4 December 2006 MEB NARSUM examination, 1 month prior to separation, noted complaints of 8/10 low back pain.  Physical examination of the lumbar spine demonstrated tenderness, but she was able to ambulate on her heels and toes without difficulty.  The goniometric range of motion (ROM) evaluation demonstrated flexion of 85 degrees (normal 90) and combined ROM of 220 degrees (normal 240).  Painful motion was not addressed.  Motor strength and sensation were normal and straight leg raise test was 0-90 with minimal increase in lumbar pain.  

At the 28 February 2007 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported intermittent low back pain aggravated by lifting, prolonged standing, or prolonged sitting, with intermittent radiation to the bilateral lower extremities.  She denied numbness or tingling but noted mild weakness in her legs in association with low back pain.  Physical examination showed tenderness.  The ROM evaluation, after repetition, showed painful flexion of 80 degrees and combined ROM of 225 degrees.  The back did not exhibit weakened movement, incoordination, or fatigability.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing forward flexion of 85 degrees and positive tenderness.  The VA also rated the back condition 10%, coded 5237, based on the C&P examination, citing painful motion.  The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB.  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), or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on all examinations proximate to separation.  There was no muscle spasm or guarding which resulted 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.  

Right Greater Trochanteric Bursitis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement, or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended hip condition, the panel agrees it cannot recommend it for additional disability rating.  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.  

AR20180016903, 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.