RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02754
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070605

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Intelligence Analyst, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  In addition to the back condition, the CI also requested review of 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 - 20070302	VARD - 20080212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Lumbar Degenerative Disc Disease	5299-5239	10%	20070920	
Bilateral Shoulder Pain	Not Unfitting	Right Shoulder Tendonitis	5201	0%		
		Left Shoulder Tendonitis	5201	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in May 2005 after a run.  An MRI showed minimal disc bulges t L4-5 and L5-S1, but there was no surgical indication.  The 7 November 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, showed painful flexion of 80 degrees (normal 90).  During the 11 December 2006 MEB NARSUM, 6 months prior to separation, the CI reported chronic low back pain that increased with any sort of movement.  The range of motion (ROM) evaluation showed painful ROM with flexion of 70 degrees and combined ROM of 195 (normal 240), after repetition.  At the MEB physical therapy (PT) examination on 23 January 2007, 4 months before separation, the CI reported low back pain.  Physical examination recorded tenderness and spasm, but gait and spinal contour were normal.  Repetitive goniometric measurements of the thoracolumbar spine showed flexion of 70 degrees and combined ROM of 195 with painful motion. 

During the 20 September 2007 VA Compensation and Pension (C&P) general examination, 4 months prior to separation, the CI walked without a limp and there was no significant spinal abnormality.  Back flexion was 45 degrees and combined ROM was 165 degrees with painful motion.  There was no ROM loss following repetition.  The 28 September 2007 C&P neurological disorder examination, 4 month after separation, revealed a steady gait, spinal tenderness and spasms.  Spinal contour was not addressed.  Back flexion was 60 degrees and combined ROM was 165 degrees with painful motion.  

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 spinal tenderness, limitation of flexion and painful motion.  The VA also rated the back condition 10%, analogously coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P general examination, citing limitation of flexion.

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 pre-separation MEB PT and MEB NARSUM ROM examinations.  The panel considered the post-separation VA ROM examinations outliers, as the preponderance of STR ROM evidence supported the 10% rating.  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 IVDS 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.

Contended PEB Condition:  Bilateral Shoulder Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated by the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition 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 the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition, and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended bilateral shoulder condition, the panel recommends no change from the PEB determination 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 20170329, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20190007130, 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.