RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04165
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20071130

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

CI CONTENTION:  “Request PDBR review for re-characterization of separation to medical retirement.”  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 - 20071004	VARD - 20081215	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain 	5299-5242	10%	Lumbosacral Degenerative Disc Disease 	5243	10%	20080709	
Frequent Headaches	Not Unfitting	Headaches	8100	Deferred	20080709	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent back surgery in May 2007 with microdiscectomy and hemilaminectomy at L5-S1, but continued to have back pain and radicular symptoms.  A post-surgical MRI in August 2007 demonstrated multilevel disk space height loss and disk desiccation from L2 through S1.  

The 7 September 2007 MEB NARSUM examination, 2 months prior to separation, noted complaints of chronic low back pain and the inability to run, jump, ruck march, carry field gear, lift or perform impact activities.  Physical examination showed an exaggerated thoracic kyphosis and lumbar lordotic curve accentuated by the sitting posture.  Coordination was intact and gait and transfers were normal.  Goniometric range of motion (ROM) testing showed, after repetition, flexion of 70 degrees (normal 90) and combined ROM of 196 degrees (normal 240) with pain in all planes of movement.  Coordination was intact and gait was normal.  

At the 9 July 2008 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI reported constant residual pain rated 7-9/10 in the lumbar spine, aggravated by bending or exposure to wet climates.  The ROM evaluation showed flexion of 90 degrees and combined ROM of 220 degrees, without painful motion but extension was limited by stiffness in the lumbar spine.  There was no additional limitation with repetitive testing due to weakness, fatigue, lack of endurance or incoordination.  Straight leg raise testing was negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing tenderness and ROM limited by pain.  The VA rated the back condition 10%, coded 5243 (intervertebral disc syndrome), based on the STR and C&P examination, citing combined ROM of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees and painful motion.  

The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB.  The criteria for rating diseases and injuries of the spine apply with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease.  The panel agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees) and painful motion, as reported on the MEB NARSUM and VA examinations; or alternatively 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 sufficient 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.  

Contended PEB Condition:  Frequent Headaches.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended headaches, the panel agrees it cannot recommend an additional disability rating.  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:

AR20190007057, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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.