RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX		CASE: PD-2017-03768 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20050417

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Food Service Specialist, medically separated for “chronic back pain” with a disability rating of 10%.

CI CONTENTION:  “Back injury rating too low.”  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 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 - 20050316	VARD - 20060417	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5242	10%	Degenerative Disc Disease Lumbar Spine Status Post Laminectomy	5242	20%	20060306	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Chronic Back Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent a lumbar microdiscectomy for a left-sided L4-5 herniated disc on 20 December 2004 after falling down a staircase while deployed. Residual low back pain continued, but she had excellent resolution of pre-operative leg symptoms. Despite physical therapy (PT), she was unable to perform duties in her military specialty.

During the 13 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported back pain. Physical examination revealed a normal gait and tenderness over the lumbar scar. The MEB PT examination, 5 days later, documented trunk flexion to 70 degrees (normal 90) and combined range of motion (ROM) of 210 degrees (normal 240), with painful motion. The 1 February 2005 MEB NARSUM noted complaints of residual back pain, and the examiner recorded some spinal tenderness around the incision site, but no lower extremity motor, sensory, or reflex abnormalities.

At the 9 June 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported chronic, daily low back pain. Physical examination showed normal gait and posture, flexion to 90 degrees and a combined ROM of 240 degrees, and no further ROM loss from pain, fatigability, incoordination, lack of endurance, or repeated testing. During a civilian clinic visit on 10 August 2005, 4 months after separation, the CI stated that the back surgery had not alleviated her back pain and that she occasionally used a walker. Physical examination revealed a normal gait, with no use of an assistance device, and no muscle spasms. Flexion was to 60 degrees (combined ROM was incomplete), and painful motion was not addressed. During the 6 March 2006 VA C&P examination, 11 months after separation, the CI reported chronic back pain with daily flare-ups, denied any loss of bowel or bladder control, and had only one period of incapacitation after the back surgery. Physical examination showed a slow but normal gait. Flexion was to 70 degrees and combined ROM was 220 degrees, with painful motion but no ROM loss following repetitive motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing ROM limited by pain with localized tenderness. The VA rated the back condition 20%, coded 5242, based on the C&P examination, citing limitation of flexion. Panel members agreed that while there was insufficient limitation of thoracolumbar spine motion to support a compensable rating under the General Rating Formula for Diseases and Injuries of the Spine, there was satisfactory evidence of painful motion IAW VASRD §4.59 to warrant a 10% rating, as recorded on the MEB PT and VA examinations. There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus a higher 20% rating was not justified on this basis. There was no evidence 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 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 §4.781a, 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:

2	PD-2017-03768

DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY
251 18TH STREET SOUTH, SUITE
385
ARLINGTON, VA 22202-3531

AR20200000141, 

Dear XXXXXXXXXXXXXXX
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.

Printed on	Recycled Paper