RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03382
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090712

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

CI CONTENTION:  The condition continues to worsen and negatively affects daily activities.  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 - 20090423	VARD - 20090826	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis, Lumbar Spine	5242	10%	Degenerative Arthritis, Lumbar Spine	5242	10%	20090731	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Degenerative Arthritis, Lumbar Spine.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in March 2007 after a tactical vehicle roll-over accident.  An MRI revealed a bulging disc at L5-S1 with moderate degenerative changes about the lumbosacral spine.  Surgical intervention was not indicated. 

The 20 March 2009 MEB NARSUM examination, 3 months prior to separation, noted complaints of constant 5-6/10 low back pain, but denied “bowel, bladder or erectile dysfunctions.”  Physical examination (PE) revealed a normal gait and the CI maintained the ability to heel-to-toe walk without difficulty.  Local tenderness without spasm was present.  The goniometric range of motion (ROM) of the thoracolumbar spine showed forward flexion of 65 degrees (normal 90) and a combined ROM of 205 degrees (normal 240).  Painful motion was present.  

At the 31 July 2009 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported low back pain aggravated by prolonged standing, sitting or walking.  He denied incapacitating episodes.  The PE revealed a normal gait and spinal contour.  Lower extremity motor strength, reflexes and sensation were normal.  Thoracolumbar ROM was recorded as normal flexion and a combined ROM of 210 degrees.  Painful motion and local muscle spasms were present. 

The panel directed attention to its rating recommendation based on the above evidence.  Both the PEB and the VA rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), citing forward flexion of 65 degrees and combined ROM of 207 degrees.  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 examinations proximate to separation.  Although there was muscle spasm noted on the VA examination, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  Additionally, 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 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:

, XXXXXXXXXXXXXXXXXX

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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.

Enclosure