RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02337
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050118

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Unit Supply Specialist, medically separated for “upper and lower back pain” with a disability rating of 10%.  

CI CONTENTION:  Review all conditions.  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 - 20041203	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Upper and Lower Back Pain 	5099-5021	10%	No VA Examination Proximate to Separation in Evidence	
Hypertension	Not Unfitting		
Occasional Retropatellar Pain Syndrome	Not Unfitting		
Plantar Fasciitis with Pes Planus	Not Unfitting		
Iliac Crest Bone Graft	Not Unfitting		
Allergic Rhinitis	Not Unfitting		
Frequent Headaches	Not Unfitting		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Upper and Lower Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in July 2001 after moving heavy boxes, and worsened during a year-long deployment from 2003-2004 and after a motor vehicle accident in June 2004.  At a physical therapy appointment on 27 July 2004, 6 months prior to separation, the CI reported chronic back pain rated at 8/10.  On examination, there was tenderness, but full range of motion (ROM).  Thoracic spine X-rays revealed no evidence of traumatic, neoplastic or significant arthritic change.  A scoliosis survey on 12 August 2004, showed a slight, gradual convex right curvature from the lower thoracic to the lower lumbar spine (less than 5 degrees) of “doubtful significance.”

During a chiropractic visit on 26 August 2004, 5 months before separation, the CI reported episodic mid and upper back pain.  Physical examination revealed tenderness, spasm and positive straight leg raise testing, but there was no evidence of abnormal spinal contour or gait. 

The 7 October 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic upper back pain.  Physical examination showed mild spasm and tenderness, but no abnormal spinal contour or gait.  The ROM evaluation showed flexion of 90 degrees (normal) and combined ROM of 200 degrees (normal 240).  During the 21 October 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported chronic high levels of back pain, and the examiner noted tenderness, but no spasm or visible spinal deformity.  Motor strength and reflexes were normal, and straight leg raise testing was negative bilaterally.  Goniometric ROM evaluation, after repetition, showed flexion of 80 degrees and combined ROM of 190 degrees, with painful motion.  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 back condition 10%, analogously coded 5021 (myositis), citing tenderness.  The panel agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees), as noted on the MEB NARSUM and MEB examinations.  Although muscle spasm was recorded at the MEB examination, it was not 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 evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  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.  

Contended PEB Conditions:  Hypertension, Retropatellar Pain Syndrome, Plantar Fasciitis with Pes Planus, Iliac Crest Bone Graft, Allergic Rhinitis and Headaches.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the upper and lower back pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended hypertension, retropatellar pain syndrome, plantar fasciitis with pes planus, iliac crest bone graft, allergic rhinitis and headache conditions, the panel recommends no change from the PEB determinations as not unfitting.  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 20170227, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20180015106, 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