RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX		CASE: PD-2017-03849 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20070606

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

CI CONTENTION:  No specific contention was made. 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 - 20070329	VARD - 20080206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Atraumatic Back Pain	5299-5237	10%	Chronic Mid-thoracic Back Sprain	UNK*	10%	20080130	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	
*Complete VARD with this information not in evidence.

ANALYSIS SUMMARY:

Atraumatic Back Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in gradually sometime in 2005 (approximately 1.5 years prior to entering the MEB process), and worsened while deployed to Iraq. Spinal X-rays in September 2006 were normal, and surgery was not recommended. At a primary care appointment on 11 December 2006, the CI reported a 6-month history of non-radicular, mid- back pain, rated at 7/10, that began without any trauma or injury. He had some mild relief with menthol cream, but was not taking any medications. Physical examination showed T5-8 midline tenderness with paraspinal spasms, but gait, motor findings and reflexes were all normal.

The 13 February 2007 MEB NARSUM examination, 4 months prior to separation, noted CI complaints of continued back pain aggravated by prolonged sitting, running, sit-ups and lifting greater than 30 pounds. He was unable to wear his individual battle gear for extended periods and felt he was unable to perform his military duties. Physical examination revealed tenderness over the left mid-thoracic region, but no deformity, effusion or warmth. There was full thoracolumbar range of motion (ROM) with increased discomfort during flexion, and a negative straight leg raise test. Motor, sensation, and reflexes were normal, with no clonus and a negative Babinski test. The final diagnosis was mechanical thoracic back pain. The 5 March 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months before separation, noted decreased thoracolumbar ROM and increased back pain on examination.

The 6 February 2008 VA rating determination summarized the 30 January 2008 VA Compensation and Pension (C&P) examination (not in evidence), 8 months after separation. The CI reported daily mid-back pain, rated at 5/10, which increased with frequent bending, running, lifting weights greater than 50 pounds, or sitting for more than 3-5 hours. He was able to walk at a regular pace without pain or use of an assistive device, and denied any radiculopathy or major incapacitating episodes or constitutional symptoms. The examiner noted the CI was in no acute distress and able to stand erect with support. There was no tenderness, muscle spasm or thoracic spine deformity, and thoracolumbar flexion was to 80 degrees (normal 90) with a combined ROM of 225 degrees, and no ROM degradation after repetition.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbar spine strain), citing tenderness and discomfort with ROM. The VA also rated the back condition 10%, (code not available in evidence), based on the C&P examination, citing 10% ROM criteria. Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) as reported on the NARSUM, examination. There was no muscle spasm or guarding 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 concluded that 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.

PD-2017-03849 

AR20190010896, XXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXX

	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.

PD-2017-03849