RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-02751 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20100121

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E5, Human Resources Specialist, medically separated for “low back pain” with a disability rating of 10%.

CI CONTENTION: No specific contention was made. 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 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 - 20091208	VARD - 20100216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Lumbar Strain	5237	10%	20090717	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Low Back Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began with an unknown etiology in October 2005. Physical therapy, medication, TENS units, and back cushions failed to allow continuation of duty in her specialty. X-ray was within normal limits.

At the 17 July 2009 VA Compensation and Pension (C&P) examination, 6 months before separation, the CI reported mild back pain since 2005, with stiffness and weakness, and inability to sit for long periods of time. Physical examination documented normal posture and gait. Thoracolumbar range of motion (ROM) was flexion to 85 degrees (normal 90) and combined ROM of 170 degrees (normal 240), with pain on all planes, but no worsening after repetition. The examiner noted tenderness of the paraspinal muscle, but no muscle spasm or guarding.

The 25 September MEB NARSUM examination, 4 months prior to separation, referenced an interview and VA physical examination performed on 4 September 2009; the NARSUM detailed the same thoracolumbar physical examination results as the 17 July 2009 C&P above.

The panel directed attention to its rating recommendation based on the above evidence. The PEB and VA both rated the back condition 10%, coded 5237 (lumbosacral strain). The PEB cited pain and limitation of motion. The VA based the rating on the C&P examination, citing forward flexion of 85 degrees and total ROM of 170 degrees on both the VA proposed and final VA rating determinations.

The panel 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 VA examination. 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 back condition.

BOARD FINDINGS: In the matter of the low back pain 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 20170415, w/atchs Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Record

2	PD-2017-02751

DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY 251 18TH STREET SOUTH, SUITE 385
ARLINGTON, VA 22202-3531

AR20200004389

Dear XXXXXXXXXXXXXX:
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.

Printed on	Recycled Paper