RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03212
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050929

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

CI CONTENTION:  Back condition review requested.  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 - 20050726	VARD - 20060117	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain	5241	10%	Residue, Postoperative Fusion of Lumbar Spine	5243-5237	20%	20050927	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Subjective Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI injured her back in 2003 while performing field exercises.  Despite non-operative management, the CI’s back pain with peripheral radiculopathy continued.  In February 2005, the CI underwent a two-level spinal decompression surgery of the lumbosacral spine.  Although having some post-operative improvement of painful symptoms, complete resolution of symptoms was not achieved.

At the 1 June 2005 MEB NARSUM examination, 4 months prior to separation, the CI endorsed the inability to tolerate wearing body armor or a Kevlar helmet.  Additionally, prolonged standing aggravated symptoms.  Physical examination (PE) revealed a non-antalgic gait and no spinal spasms.  Lower extremity strength, sensation and reflexes were normal.  The 8 June 2005 physical therapy range of motion (ROM) evaluation showed pain-limited forward flexion of 25 degrees (normal 90) and pain-limited combined thoracolumbar ROM of 75 degrees (normal 240).  The examiner recorded the CI had 6/10low back pain (LBP) that traveled down into the right thigh.  During the 9 June 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported a history of back pain with numbness and tingling down to the back of her right thigh.  The PE revealed a normal gait, spinal tenderness, and limitation of spinal movement in all directional planes, but numerical measured ranges were not listed.

At the 27 September 2005 VA Compensation and Pension (C&P) examination, 2 days before separation, the CI reported intermittent 5-6/10 LBP with intermittent pain extension into the left leg.  Her PE revealed an altered gait (limp) favoring the left leg.  Spinal tenderness was present.  Spinal ROM was measured at 60 degrees of forward flexion and a combined ROM of 210 degrees.  Repetitive motion had no additional changes in ROM.  Peripheral muscle strength, sensation and reflexes were normal.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5241 (spinal fusion), citing thoracolumbar ROM limited by pain.  The VA rated the back condition 20%, dual coded 5243-5237 (intervertebral disc syndrome (IVDS) - lumbosacral strain), based on the C&P examination, citing functional loss due to pain.  The panel considered the somewhat disparate examinations and agreed the pre-separation C&P examination held the greatest probative rating value due to its more detailed clinical assessment and its close reference to the date of separation.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion greater than 30 degrees but not greater than 60 degrees, as reported on the probative VA examination.  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 recommends a disability rating of 20% for the low back condition, coded 5241.  

BOARD FINDINGS:  In the matter of the low back condition, the panel recommends a disability rating of 20%, coded 5241 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain	5241	20%	

The following documentary evidence was considered:

AR20180015264, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

The Department of Defense Physical Disability Board of Review (DoD PDBR)
reviewed your application and found that your disability rating should be modified but
not to the degree that would justify changing your separation for disability with
severance pay to a permanent retirement with disability. I have reviewed the Board’s
recommendation and record of proceedings (copy enclosed) and I accept its
recommendation. This will not result in any change to your separation document or the
amount of severance pay. A copy of this decision will be filed with your Physical
Evaluation Board records. I regret that the facts of the case did not provide you with the
outcome you may have desired.
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.
A copy of this decision has also been provided to the Department of Veterans Affairs.

Enclosure