RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02547
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070420

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Trainee, medically separated for “chronic thoracolumbar pain” with a disability rating of 10%.

CI CONTENTION:  Review of 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 - 20070409	VARD - 20070908	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Thoracolumbar Pain	5299-5237	10%	Thoracolumbar Spondylosis	5299-5239	10%	20040714	
Asthma	Not Unfitting	Asthma	6602	0%		
Allergic Rhinitis		No VA Placement	
Right Hip Bursitis			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Chronic Thoracolumbar Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began insidiously in December 2006 and occurred concurrently with a tingling sensation in the right lower extremity.  Thoracolumbar spine X-rays revealed minimal degenerative changes, and surgery was not indicated.  Physical therapy (PT) and medication did not provide pain relief.  

During the 7 March 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported occasional right leg numbness and tingling.  Physical examination (PE) showed lower spine tenderness, and range of motion (ROM) testing revealed back flexion of 80 degrees (normal 90) and a combined ROM of 220 (normal 240); painful motion was not addressed.  At the MEB NARSUM examination the same day, the CI reported thoracolumbar pain with occasional stocking-glove sensation in the right lower extremity below the knee.  The PE showed tenderness and the ability to rise on heels and toes without difficulty.  Motor activity and peripheral strength were normal, but gait, spinal contour, guarding and spasms were not addressed.  The MEB PT ROM evaluation the same day showed thoracolumbar flexion of 85 degrees and combined ROM of 225 degrees, with painful motion. 

At the 22 June 2007 VA Compensation and Pension (C&P) examination, 2 month after separation, the CI reported continued thoracolumbar pain.  The PE revealed spinal tenderness, but a normal gait.  The ROM study showed flexion of 75 degrees and combined ROM of 225 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing pain limited motion and localized tenderness.  The VA also rated the back condition 10%, but analogously coded 5299-5239 (spondylolisthesis or segmental instability), based on the C&P examination, citing limitation of spinal motion.  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/or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the examinations proximate to separation.  There was no evidence of intervertebral disc syndrome 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.

Contended PEB Conditions:  Asthma, Allergic Rhinitis and Right Hip Bursitis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The contended conditions were not profiled or implicated by 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 chronic thoracolumbar pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended asthma, allergic rhinitis and right hip bursitis, the panel recommends no change from the PEB’s 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 20170314, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20190006047, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

DearXXXXXXXXXXXXXXXXXX

	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.