RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03482
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060711

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Cable Systems Installer/Maintainer, medically separated for “chronic non-radiating mid-back pain” with a disability rating of 0%. 

CI CONTENTION:  Review all conditions.  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 - 20060608	VARD - 20061211	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mid-Back Pain	5299-5237	0%	Thoracolumbar Strain	5242	10%	20060919	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Mid-Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in 1998 without trauma or injury.  However, in July 2004 he fell from a ladder and later that year was involved in a motor vehicle accident.  Thoracic spine X-rays in February 2006 showed mild compression abnormalities, but a thoracic spine MRI in March 2006 was normal.  Lumbar spine X-rays in February 2006 were normal.  

During the 19 May 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported constant back pain and spasms with intermittent right arm numbness.  Physical examination showed tenderness.  The range of motion (ROM) evaluation showed flexion of 110 degrees (normal 90) and combined thoracolumbar ROM of 235 (normal 240) with a negative straight leg raise test.  The 22 May 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of sharp 5/10 mid-back pain with lifting more than 20 pounds and spasm of the right thoracic and lumbar paraspinal muscles.  Physical examination showed muscle spasm, but the gait was normal and there was no mention of abnormal spinal contour.  Sensation was intact and motor strength and reflexes were normal.  The ROM evaluation, after repetition, showed flexion of 90 degrees, extension of 25 degrees (normal 30) and right and left rotation of 45 degrees (normal 30).  There were no lateral flexion measurements.  

At the 19 September 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported muscle spasms over his mid to low back, but denied radiation of back pain, incapacitating episodes or loss of bowel or bladder control.  Physical examination showed a smooth and coordinated gait, tenderness and increased lordosis, but no spasm.  The ROM evaluation, after repetition, showed flexion of 80 degrees due to pain, weakness and lack of endurance.  The combined thoracolumbar ROM was 230 degrees.  There was pain in all planes of motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, analogously coded 5299-5237 (lumbosacral strain), citing “rated for spasm.”  The VA rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing functionally limited forward flexion of the back to 80 degrees.  The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on all examinations.  It was noted that muscle spasm was present on the NARSUM examination, however there was not an associated abnormal gait or abnormal spinal contour to support the next higher rating of 20%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the back condition, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5299-5237 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	
Chronic Non-Radiating Mid-Back Pain	5299-5237	10%	

AR20180015379, 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.