RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01980
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “degenerative disc disease” with a disability rating of 10%.  

CI CONTENTION:  Review of “two fractured vertebrae” requested along with 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 - 20071228	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Disc Disease	5299-5242	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Degenerative Disc Disease.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s low back condition began in 2005 and was aggravated in 2006 when he fell in a hole while deployed.  X-rays from May 2007 demonstrated a normal lumbosacral spine.  An MRI on 15 June 2007, 8 months prior to separation, revealed bilateral spondylolysis without evidence for spondylolisthesis at L5-S1, with associated mild articular facet degeneration at this level.  There was a minimal disc bulge at L4-L5, but otherwise, the lumbar spine MRI was negative.  An EMG/NCV study from 28 August 2007, 6 months prior to separation, revealed a normal study of the lower extremities.  The 13 September 2007 orthopedic clinic evaluation noted a complaint of chronic pain.  Physical examination revealed a normal gait and stance.  The lumbosacral spine exhibited a normal appearance but there was lumbar tenderness.  

During the 14 November 2007, physical therapy (PT) evaluation, 3 months prior to separation, range of motion (ROM) was flexion of 90 degrees (normal) and combined ROM of 210 degrees (normal 240) after repetition.  Lateral rotation measurements were taken using a goniometer while all other measurements were taken using an inclinometer.  Lumbar paraspinal muscles were tender at L3-L5.   There was no muscle spasm, guarding, abnormal gait, or spinal contour. At a PT appointment 2 weeks later on 4 December 2007, the CI reported he had started to get back in the gym and was able to do limited workouts again.  On examination, the CI did not walk with an antalgic gait.  Lumbar paraspinal muscles were tender bilaterally.  Flexion was limited by tightness, extension was normal (with pain) and rotation was full with pain at the end of the range.  

During the 17 December 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported consistent pain and soreness in the lower back area.  Physical examination revealed the lower back was tender with mild spasm, but was “otherwise normal.”  The same-day MEB NARSUM examination noted complaints of constant back pain, often making sleep difficult.  Physical examination showed lumbar paraspinous muscles were tender with mild spasm noted on the right.  ROM was consistent with goniometer measurements and lower extremity strength was 5/5.  Sensation was intact and deep tendon reflexes were normal.  Straight leg raise was negative bilaterally and heel, toe and tandem walk were normal.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, analogously coded 5242 (degenerative arthritis of the spine), citing thoracolumbar ROM limited by pain, tenderness and spasm noted during the examination; gait was normal.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of the combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB PT examination.  The panel also noted an alternate 10% but no higher, rating option, was justified for localized lumbar tenderness as noted by the PEB.  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 low back condition.  

BOARD FINDINGS:  In the matter of the 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 20170223, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20180010156, 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.

Sincerely,					      
Enclosure