RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04138
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060411

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

CI CONTENTION:  “When the evaluation period was active, I missed a couple of doctor’s appointments because I was unable to get the time off due to new employment.  My rating is based on incomplete evidence.”  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 - 20060328	VARD - 20060511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
…Low Back Pain	5299-5237	10%	Degenerative Disc Disease with Disc Herniation; Lumbar Spine	5242	10%	STR	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in September 2005 after tripping and falling while running on uneven terrain and carrying a 160-pound backpack.  The CI was offered and declined surgical intervention.  The 23 January 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of low back with radiation into the buttocks, bilateral legs and feet.  Physical examination showed negative straight leg raise bilaterally, and normal lower extremity strength and reflexes.  There was tenderness over the L3 spinous process and bilateral paraspinal tenderness at T12.  Thoracolumbar range of motion (ROM) measurements revealed flexion to 90 degrees (normal) and combined ROM of 215 degrees (normal 240), after repetitive motion.  The examiner noted the CI had an antalgic gait and used crutches for ambulation.  During the 2 February 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), he reported low back pain, and the examiner documented “mild scoliosis or poor posture to left.”  There was no VA examination proximate to separation in evidence.  
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing normal contours, full motion for body habitus, some paraspinal tenderness and no clinical signs of separately unfitting radiculopathy.  The VA also rated the back condition 10%, but coded 5242 (degenerative arthritis of the spine), based on the STR, citing evidence of painful motion.  While the MEB examiner noted possible scoliosis, this was not verified by other examinations to warrant a higher 20% rating.  Although there was insufficient limitation of flexion to support a compensable rating, the panel agreed a 10% rating was justified for combined ROM and tenderness.  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 low 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.  

The following documentary evidence was considered:

AR20200000655, XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXX:

	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.