RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-01938
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090923

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Wheeled Vehicle Mechanic, medically separated for “chronic thoracic back pain secondary to repetitive strain injury” with a disability rating of 10%.  

CI CONTENTION:  “Back injury left me unable to perform most jobs”.  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 - 20090707	VARD - 20100504	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Thoracic Back Pain …	5237	10%	Myofascial Syndrome, Thoracic 	5237	10%	20090915	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Thoracic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered an atraumatic onset of mid-back pain in May 2007 associated with repetitive heavy lifting.  Imaging (X-rays, MRI) was normal (other than noting anatomic thoracic kyphosis) and there were no neurological symptoms or surgical indications.  There were multiple STR clinical entries that documented grossly normal or modestly limited thoracolumbar range of motion (ROM) and a normal gait.  There were no contrary findings, and no documentation of abnormal spinal contour due to guarding or spasm.  

The 2 June 2009 MEB NARSUM examination, 4 months prior to separation, documented that pain was “present always to a very low degree, but repetitive lifting can produce severe pain.”  The physical examination recorded a normal gait, anatomic kyphosis without spasm or guarding, tenderness, and normal neurological findings.  Measured ROM was significantly greater than normal in all planes, recording values that were implausible enough to mitigate the probative value of that evidence.  

The 15 September 2009 VA Compensation and Pension (C&P) examination, a week before separation, documented mid-back pain of “moderate” severity that was intermittent throughout the day and aggravated by heavy lifting.  The physical examination recorded a normal gait, normal spinal contour, tenderness without spasm, and normal neurological findings.  Measured ROM was flexion to 90 degrees (normal) with a combined ROM of 240 degrees (normal), specifying painful motion but no ROM degradation with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (thoracolumbar strain), citing tenderness and specifically referencing the VASRD §4.71a general spine formula.  The VA, based on the C&P evidence, conferred the same rating under the same code, also citing tenderness.  

There was no ROM limitation in evidence satisfying minimum 10% criteria, although the §4.71a 10% criteria of tenderness and painful motion were satisfied by the evidence.  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 thoracolumbar condition.  

BOARD FINDINGS:  In the matter of the thoracolumbar 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.  

AR20180015095, 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.