RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04068
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060213

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Automated Logistics 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 - 20051130	VARD - 20060509	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Chronic Low Back Pain with L5-S1 Degenerative Disc Disease (DDD)	5243	40%	20060316	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition reportedly began in November 2004 after downloading tires from a truck, although a physical therapy (PT) clinic note in December 2004 indicated the back pain began 2-3 months earlier without trauma.  An MRI on 15 February 2005 demonstrated minimal DDD at L5-S1 with a right foraminal annular tear. There was no disc herniation, but there were endplate signal changes to the left of L5-S1.   At an orthopedic visit on 21 April 2005, the CI was noted to not be a surgical candidate, and during a chiropractic examination on 28 June 2005, the provider found of tenderness along the L4, L5, and S1 spinous processes and bilateral lumbar erectors, as well as increased left multifidus and gluteus medius muscle pain; range of motion (ROM) was “reduced.”  Nonsteroidal medication, PT, and chiropractic care failed to allow return to duty in her military specialty.  

During the July 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported an inability to road march, run, or lift due to pain.  Physical examination showed pain on movement, “very limited” flexion, and no neurologic deficit.  The 28 July 2005 MEB NARSUM examination noted complaints of low back pain and an inability to perform the military specialty duties.  Physical examination showed normal findings and no lower extremity neurological deficits.  An MRI on 7 October 2005 demonstrated DDD predominantly at L5-S1 causing mild bilateral neural foraminal narrowing with abutting of the left L-5 existing nerve root. There was also an L5-S1 superimposed right foraminal eccentric disc bulge with a right foraminal annulus tear, and a minimal exaggerated lumbar lordosis.  The radiologist noted “findings are unchanged given the difference in technique” from the February 2005 MRI findings.  At the 11 October 2005 MEB PT ROM study, 4 months before separation, CI walked with a cane and had normal reflexes and muscle strength.  After repetition, ROM measurements showed lumbar flexion to 15 degrees (converts to 45 degrees thoracolumbar flexion (normal 90)).  

At the 16 March 2006 VA Compensation and Pension (C&P) joints examination, 1 month after separation, the CI reported back pain with occasional flare-ups, but no radiation, bowel, or bladder dysfunction.  The examiner found back ROM “surprisingly limited to only 10 degrees flexion, 0 degrees right and left bending.  She has 0 degrees extension and 0 degrees of right and left rotation, carried out with pain.”  There were no motor strength, sensation, or reflex deficits, and no muscle spasms.  Spinal X-rays performed the same day were normal.  At the 25 March 2006 VA C&P general examination, one week later, the examiner noted a normal spine and gait with no assistive aids for walking, but did not mention ROM measurements.  At a physical medicine and rehabilitation visit on 25 April 2006, 2 months after separation, a physical therapist noted ROM within functional limits except for mild lumbar and hamstring muscle tightness with guarding of all movements due to complaints of lumbar pain.  Trunk forward flexion was documented as 60% (approximately 55 degrees), extension as 25% (approximately 5-10 degrees), side bending on the right as 30% (approximately 10 degrees), and on the left as 20% (approximately 5 degrees).  Strength was normal and light touch was intact.  She had an antalgic gait, but did not bring her cane.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain), citing reduced ROM due to pain. The VA rated the low back condition 40%, coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P examination, citing thoracolumbar forward flexion of 30 degrees or less.  Panel members noted that the MEB and VA examinations recorded “lumbar,” “back,” or “trunk” measurements and not thoracolumbar ROM as required by VASRD guidelines.  The panel converted the MEB PT lumbar flexion of 15 degrees to thoracolumbar flexion of 45 degrees, and while the VA “back” flexion measurement of 10 degrees might be converted to 40 degrees, it was unclear whether this was a lumbar measurement.  If the VA examiner’s measurement was for thoracolumbar flexion to 10 degrees and each of the other planes of motion actually showed ROM to 0 degrees, the CI would have had very significant, patently obvious difficulty getting up, moving about, or lying down, which was not the case.  Panel members noted that the October 2005 MRI findings of bilateral neural foraminal narrowing  and disc bulge were more compatible with thoracolumbar flexion measurements of 40-55 degrees rather than 10 degrees, and furthermore, 5 weeks after the C&P examinations, a physical therapist reported flexion of 60%, which converts to approximately 55 degrees of thoracolumbar flexion.  Therefore, the panel favored a 20% rating for thoracolumbar flexion greater than 30 degrees but not greater than 60 degrees.  There was no evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the low back condition, coded 5237.

BOARD FINDINGS:  In the matter of the low back condition, the panel recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  
The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5237	20%	

AR20200000647, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
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. 

A copy of this decision has also been provided to the Department of Veterans Affairs.