RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02765
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20080901

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Cryptologic Linguist, medically separated for “degenerative arthritis of the spine” with a disability rating of 10%.   

CI CONTENTION:  “Extent of injuries not realized by reviewers.  Effects of injury have led to significant health problems, multiple surgeries, and a 90% VA rating.”  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 - 20080609	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis of the Spine	5242	10%	No VA Examination Proximate to Separation in Evidence	
Hypertension	Not Unfitting		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Degenerative Arthritis of the Spine.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in August 2007 while deployed to Iraq without evidence of injury or trauma.  The 26 November 2007 MEB primary care clinic examination showed tenderness.  There was “full range of motion (ROM)” with pain on movement.  Spasms were present.  The CI had a stooped gait.  During the 14 May 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported frequent back pain and occasional tingling in his feet.  Physical examination showed tenderness.  

The 22 May 2008 MEB NARSUM examination, 3 months prior to separation, noted constant 4-9/10 back pain with frequent spikes of radiating pain down his bilateral legs posteriorly to his feet, worse with activity or at the end of the day.  He experienced exacerbation by walking more than 30 meters, running, walking up or down stairs, lifting or carrying more than 20 pounds, sitting in place for more than 15 minutes or standing for more than 10 minutes.  The CI reported symptomatic flare-ups 4 times per day, occurring with increased activity.  The duration of the flare-ups could last from 2-3 hours.  Physical examination showed a normal gait.  There was tenderness. There was no muscle spasm, muscle atrophy or guarding.  There was no abnormal spinal contour.  Thoracolumbar ROM measurements were active flexion of 80 degrees (normal 90) and combined ROM of 210 degrees (normal 240).  There was increased pain with extension after three repeated trials, but no evidence of further limitation.  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%, coded 5242 (degenerative arthritis of the spine), citing forward flexion functionally limited to 78 degrees by pain.  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 combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the NARSUM 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 of 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:  Hypertension.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in 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 and 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 hypertension 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 20170425, w/atchs
Exhibit B.  Service Treatment Record

AR20180008676, 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