RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03585
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050930

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Communication Locator/Interceptor, medically separated for “chronic upper and lower back pain” with a disability rating of 10%  

CI CONTENTION:  The back pain continues to impact daily activities.  He also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20050803	VARD - 20060309	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Upper and Lower Back Pain	5237	10%	Degenerative Changes and Strain	5242	10%	20060119	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Upper and Lower Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s chronic upper and lower back pain began in March 2004 when he was running on uneven terrain with 30 pounds of equipment.  No history of injury or other trauma was reported.  X-rays of the thoracic spine in August 2004 showed minimal degenerative changes.  An MRI of the lumbar spine in November 2004 was normal as was an MRI of the thoracic spine in January 2005.  No surgery was recommended.  

The 2 May 2005 MEB NARSUM Addendum, 4 months prior to separation, noted complaints of constant back pain with the lower thoracic area identified as the primary source of pain.  The pain did not radiate to his legs.  No bowel or bladder dysfunction was reported.  Physical examination showed the spine was in normal alignment.  Reflexes and sensory were normal.  Range of motion (ROM) testing was performed with an inclinometer showing forward flexion of the thoracolumbar spine at 60 degrees on 3 measurements, extension at 20 degrees, lateral flexion in each direction at 40 degrees, and rotation at 50 degrees in each direction.  Pain during ROM was reported.  

The 24 June 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic back pain that was present all the time and did not radiate.  Physical examination showed a mild limp with mild difficulty getting up from the chair.  Tenderness was present in the lumbar region.  ROM showed lumbar flexion at 45 degrees without pain (normal 90), extension at 10 degrees, and bilateral flexion and rotation were 30 degrees.  Combined ROM was 175 degrees (normal 240).  

At the 19 January 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported thoracolumbar spine pain as constant, localized, and sharp in nature along with dull pain.  No radiating pain or incapacitation was reported.  Physical examination showed normal gait and posture.  Muscle spasm was present in the lumbar region, and abnormal curvature of the spine was not recorded.  Tenderness was noted on examination.  Straight leg raise test bilaterally was negative.  ROM showed flexion at 90 degrees (normal) and combined ROM at 240 degrees (normal) with painful motion.  The joint function of the spine was additionally limited after repetitive use, with pain being the major factor.  There was no sign of intervertebral disc syndrome or permanent nerve root involvement.  

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 tenderness, flexion of 60 degrees, and motion limited by pain.  The VA also rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing flexion at 90 degrees, tenderness, and muscle spasms with a normal gait.  

The panel majority agreed that a 10% rating, but no higher, was justified for the presence of painful motion and tenderness as reported on the VA examination.  Although the first NARSUM recorded 60 degrees of flexion, the examiner used an inclinometer rather than a goniometer.  An inclinometer is not compliant with VASRD §4.46 (accurate measurement).  The second NARSUM recorded lumbar ROM rather than thoracolumbar ROM.  Although there was muscle spasm, 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.  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 majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic upper and lower back condition.  

BOARD FINDINGS:  In the matter of the chronic upper and lower back condition and IAW VASRD §4.71, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 20% and did not elect to submit a minority opinion.  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.  

AR20180015302, 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.