RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXXX.

CASE: PD-2017-03905

BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20090323

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Dental Specialist, medically separated for “low 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 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 - 20081123	VARD - 20090609	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5099-5237	10%	Lumbar Strain	5237	10%	20090209	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 90%	

ANALYSIS SUMMARY:

Low Back Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a history of chronic low back pain from heavy lifting dating back to 1996. Imaging (serial MRI’s) did not reveal any significant disc disease, multiple neurological examinations were normal, and surgery was not indicated. Provider entries in the STR documented grossly normal to non-specifically limited range of motion (ROM). An orthopedic entry of 26 September 2008 documented flexion limited to knee level (~45-60 degrees), but subsequent examiners noted normal or near normal ROM. There was no STR evidence of more significant ROM limitation, incapacitating episodes or abnormal gait/spinal contour.

The 23 November 2008 MEB NARSUM examination, 4 months prior to separation, noted CI complaints of a persistent backache, rated at 3-4/10, and increased with prolonged sitting, standing, or increased activity. The physical examination made no note of abnormal gait or spinal contour, tenderness, spasm, or other ratable findings. Measured ROM (accommodating documented DeLuca deductions) showed flexion to 65 degrees (normal 90) and combined ROM of 160 degrees (normal 240), specifying painful motion.

At the 9 February 2009 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported daily mild back pain with occasional exacerbations that limited sitting to 15-30 minutes and prohibited “shoveling ... or other heavy duty activities.” The physical examination recorded a normal gait, “mild” reverse lordosis with no spasm or guarding, and normal neurological findings. Measured ROM (accommodating documented DeLuca deductions) revealed flexion to 75 degrees and combined ROM of 195 degrees, specifying painful motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the lumbar condition 10%, coded 5099-5237 (analogous to lumbosacral strain), citing limitation of motion and pain. The VA conferred the same rating under the same code (non- analogous), based on the C&P examination and citing the applicable VASRD §4.71a criteria (see below). 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) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB and VA examinations. 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 there was insufficient cause to recommend a change in the PEB adjudication for the lumbar condition.

BOARD FINDINGS: In the matter of the lumbar 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.

2	PD-2017-03905

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

AR20200000231,

Dear XXXXXXXXXXX

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.

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