RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03950
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090825

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Automated Logistical Specialist, medically separated for “lumbosacral strain” with a disability rating of 10%.   

CI CONTENTION:  His back condition has worsened and significantly interferes with his daily activities.  “Also at night I am unable to sleep due to severe pain and depression…”  The CI requested review of an additional condition (depression) 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 – 20090717	VARD - 20091121	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Lumbar Strain	5237	10%	20090929	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began while deployed in December 2004, after he slipped and lost his balance causing him to hit his back against a metal stand while working in the motor pool.  He was treated conservatively and completed his deployment.  In November 2005 his back pain was exacerbated while doing sit-ups and continued to worsen, but he was able to deploy again (October 2007-December 2008).  An MRI in September 2008 was normal.
At the 18 March 2009 orthopedic clinic appointment, 5 months prior to separation, the CI reported lower back pain in the lumbosacral region with associated paresthesia to both lower extremities and minimal relief of symptoms with conservative treatment.  On examination the lumbosacral spine motion was normal, but pain was elicited.  There were no muscle spasms, but the iliolumbar region exhibited tenderness.  Posture, gait lumbar curvature, and lordosis were normal.  The examiner cited exaggerated and inconsistent responses.  Thoracolumbar range of motion (ROM) measurements performed by physical therapy (PT) on 8 May showed flexion of 60 degrees (normal 90) and combined ROM of 180 degrees (normal 240) after repetition.  ROM limitations were due to pain.  There was tenderness and spasm over the lumbar paraspinals.  The CI was guarded in all planes of testing, however the examiner was silent regarding gait.  Posture was unremarkable.  

The 6 July 2009 MEB NARSUM examination, 2 months prior to separation, noted complaints of back pain aggravated by prolonged standing, sitting, bending, stooping, and heavy lifting.  The examiner stated the thoracolumbar ROM was “normal confirming the goniometric results,” however no measurements were found in evidence.  There was no evidence of muscle atrophy and motor, sensory and reflexes were normal as was straight leg raise testing. 

At the 29 September 2009 VA Compensation and Pension (C&P) examination, one month after separation, the CI reported constant pain with stiffness, fatigue, spasms, and numbness.  He also reported leg weakness.  Physical examination showed a normal gait and posture.  There was no evidence of radiating pain on movement.  Tenderness was noted, but no muscle spasms.  
There was no guarding and the examination did not reveal any weakness.  ROM of the thoracolumbar spine was flexion of 90 degrees and combined ROM of 240 degrees after repetitive movement.  X-rays were normal.  The examiner diagnosed lumbar strain with subjective low back pain and objective evidence of tenderness.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbar spine strain), citing 62 degrees of forward flexion and combined ROM of 180 degrees.  The VA also rated the back condition 10%, coded 5237, based on the C&P examination, citing muscle spasms, guarding or localized tenderness not resulting in an abnormal gait or abnormal spinal contour.    The panel noted that the limitation of thoracolumbar motion recorded in the MEB PT examination met the threshold for a 20% rating when properly rounded to the nearest five degrees, however the orthopedic, NARSUM and VA examination met the threshold for a 10% rating supported by painful motion or tenderness.  The panel considered all the evidence and agreed the VA examination was more consistent with outpatient notes and more reflective of the anticipated severity based on the clinical pathology (normal X-rays and MRI) and was more proximate to separation.  Therefore the panel placed greater probative value on the VA examination.    

There was no limitation of thoracolumbar spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine, however the VA examination noted the presence of localized tenderness.  A 10% rating was therefore warranted.  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 back condition.  

BOARD FINDINGS:  In the matter of the lumbosacral strain 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.    

AR20190010919, XXXXXXXXXXXXXXX

Dear XXXXXXXXXX:

	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.