RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02521
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “lumbosacral strain” with a disability rating of 10%.   

CI CONTENTION:  Review requested of back condition and 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 - 20090127	VARD - 20090805	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Thoracolumbar Strain	5237	10%	20090312	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s lumbosacral condition began in March 2005 after tripping and falling approximately 3 feet into a ditch on a stack of logs.  He was given nonsteroidal agents and referred to physical therapy (PT) at the time, but after another fall from a ladder, PT and injection therapy provided no pain relief.  An MRI showed mild scoliosis and developmental type central canal spinal stenosis without nerve root or cord involvement.  No surgery was indicated.  

During the 1 October 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported recurrent back pain with numbness and tingling of  the legs.  Physical examination showed lumbar spine tenderness and decreased range of motion (ROM), but the CI could stand on his toes and heels.  At the 19 December 2008 MEB NARSUM examination, 4 months before separation, physical examination revealed slight low back tenderness, but no visual abnormalities or spasm.  Sensation and motor functions were intact.  Range of motion (ROM) showed forward flexion to 90 degrees (normal) with combined ROM of 220 degrees (normal 240).  A 15-degree decrease in all ROM measurements was due to pain following repetition.  

At the 12 March 2009 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported daily pain, with aggravation up to 20 times per month, but no radiating pain to the lower extremities.  Physical examination revealed no evidence of lumbar spasm or scoliosis, and ROM testing showed flexion to 75 degrees with a combined ROM of 197 degrees; painful motion was noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated lumbosacral strain 10%, coded 5237 (lumbosacral strain) citing tenderness, full ROM, and no spasm.  The VA also rated the thoracolumbar strain 10%, coded 5237, based on the C&P examination, citing limited flexion with pain.  Members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the NARSUM and VA examinations proximate to separation.  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 lumbosacral condition.  

BOARD FINDINGS:  In the matter of the lumbosacral strain 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 20170315, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190006039, 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.

A copy of this decision has been provided to the counsel you listed on your application, XX. XXXXXX XXX, Veteran Service Officer, XXXXXX War Veterans, XX XXX XXXXX, XXXXXXXX, XX XXXXXX.