RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03125
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20050629

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

CI CONTENTION:  She requested all conditions be reviewed.  Her lumbar area has increased pain and mobility issues and she has had thyroid problems for over 12 years.  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 - 20050414	VARD - 20050728	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	10%	Lumbar Spine DDD	5242	10%	20050503	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in July 2003 after unloading rations from a truck.  A bone scan on 20 July 2004 was normal, but an MRI on 17 September 2004 showed moderate degenerative disc disease (DDD) at L4-5 and L5-S1 and mild DDD at L3-4, with maintained spinal canal and neural foramina calibers.  

The 16 November 2004 MEB NARSUM examination, 7 months prior to separation, noted complaints of low back pain aggravated by forward flexion, tying shoes, and coughing.  Physical examination showed a slight decrease in lumbar lordosis and mild muscle spasms and tenderness.  Range of motion (ROM) measurements were not provided, but a 10 February 2005 physical therapy (PT) evaluation, 4 months before separation, showed flexion of 65 degrees (normal 90) and combined ROM of 140 (normal 240) after repetition.  On 15 March 2005, the date of the MEB and 3 months before separation, PT ROM measurements showed flexion of 65 degrees and a combined ROM of 200 degrees, also after repetition.  The examiner noted painful motion with flexion and extension.  

At the 3 May 2005 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported she was unable to jog or perform vigorous activities or heavy lifting, but could undertake other activities of daily living without difficulty.  Physical examination showed a normal gait with no paraspinous muscle spasm or tenderness.  The examiner reported “nearly normal ROM” with lordosis, however, ROM measurements or painful motion were not recorded.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing mild muscle spasms and painful motion.  The VA also rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P evaluation, citing painful 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 combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the PT ROM examinations.  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.  

BOARD FINDINGS:  In the matter of the chronic 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 20170426, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006198, 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