RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX
CASE:  PD-2017-02899
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, 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’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 - 20090624	VARD - 20090729	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracolumbar Strain 	5237	10%	Thoracolumbar Strain	5237	10%	20090220	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Thoracolumbar Strain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in May 2007 after heavy lifting.  Radiographic and electrodiagnostic studies were normal.    There was no anatomic abnormalities that clinically correlated with the back pain.  The 1 October 2008 physical therapy clinic examination documented no tenderness, muscle spasm, guarding, abnormal gait, or abnormal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.  The goniometric range of motion (ROM) study of the thoracolumbar spine showed pain-limited flexion of 70 degrees (normal 90) and combined ROM of 215 degrees (normal 240) after repetitive motion.  There was no functional loss due to fatigue, weakness, lack of endurance or incoordination during flare-ups or repetition.  

At the 20 February 2009 VA Compensation and Pension (C&P) examination, 7 months before separation, the CI reported daily upper and middle back pain, pain with walking and shooting pain down the legs.  Physical examination showed normal posture and gait with no spasm, atrophy, guarding or weakness.  Pain-limited flexion was 70 degrees and combined ROM was 220 degrees, after repetitive motion.  

The panel directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated the back condition 10%, coded 5237 (lumbosacral strain), based on the STR and VA C&P examinations, citing forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees.  

The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB.  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) or combined ROM (greater than 120 degrees, but not greater than 235 degrees), as reported on the PT and VA C&P examinations.  Considering VASRD §4.40, §4.45, and §4.59, the panel agreed that there was some additional functional limitation due to painful motion; however, the evidence did not show additional functional limitations which approximated the criteria for the next higher rating.  There was no muscle spasm or guarding which resulted 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 back 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 20170423, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

		PD-2017-02899

AR20190009884, XXXXXXXXXXXXXX 

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.

	

	PD-2017-02899