RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:	CASE:  PD-2017-04220
BRANCH OF SERVICE:  ARMY	SEPARATION DATE: 20040417

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Food Service Specialist, medically separated for “low back pain…with intermittent left radiculitis” with a disability rating of 0%.

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 - 20040202	VARD - 20040602	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain…	5237	0%	L4-5, L5-s1 Disc Protrusion and DDD with Left Lower Extremity Radiculitis	5243	40%	20040309	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Low Back Pain (LBP). According to the service treatment record and MEB narrative summary (NARSUM), the CI developed LBP with radicular symptoms to the left lower extremity in August- October 2001 while in basic training. She denied any specific incident or trauma, and MRI studies on 21 July 2003 revealed discogenic disease at L4-5 and L5-S1. At the 6 August 2003 neurosurgery consult, she reported LBP aggravated by prolonged sitting and standing, with pain radiating to the lower extremities, left greater than right. Physical examination noted mild lumbar region tenderness but a normal gait. Straight leg raise testing was negative bilaterally and strength/reflexes were normal; surgery was not recommended. At a pain clinic visit on 14 August 2003, the provider noted mild low back tenderness but a normal gait and neurological findings. Range of motion (ROM) measurements were within normal limits.

During the 31 October 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported back pain with numbness and tingling in the left leg and sometimes the right. Physical examination revealed lumbosacral tenderness with mild paraspinal muscle spasms. There was no evidence of sciatica and ROM was not documented. At

the MEB NARSUM examination, the same day, the CI complained of back pain, rated at 3-4/10, but no radiation or neurologic issues. Physical examination showed a normal gait pattern and posture with no tenderness. She could “flex forward placing her fingertips 1.5 cm from the superior portion of the patella.” Neurological examination was unremarkable. Goniometric thoracolumbar ROM measurements performed by physical therapy (PT), also on the same day, revealed flexion to 90 degrees (normal) and combined ROM of 240 degrees (normal), after three repetitions and painful motion. Gait was within functional limits with some lumbar flexion, and thoracic kyphosis was noted.

At the 9 March 2004 VA Compensation and Pension (C&P) general examination, 1 month before separation, the CI reported persistent LBP, rated at 8/10, with daily radicular symptoms going down the left lower extremity. She had flare-ups once a month, which decreased ROM by 50%, but denied any incapacitating episodes. The examiner noted that she was in no acute distress at the time of the examination. However, physical findings showed an abnormal gait and that she walked with her back flexed minimally and slowly. There was no tenderness, spasm or abnormal curvature of the spine. Thoracolumbar flexion was to 30 degrees and combined ROM was 75 degrees, with discomfort. However, the examiner stated the measurements were taken without hip involvement. Repetitive motion did not increase the pain or decrease motion. Motor strength was normal and sensation was decreased in the left lower extremity.

At the 1 February 2005 C&P spine examination, 9 months after separation, the CI reported LBP at least 5 days a week, rated at 8-9/10 and described as aching and sharp with lower extremity radicular symptoms once a week. She denied incapacitating episodes and was working in a retail job, which was difficult because she had to stand all day. The examiner noted no acute distress at the time of the examination, and documented tenderness but a normal gait and no muscle spasms. Thoracolumbar ROM measurements showed flexion to 45 degrees and a combined ROM of 90 degrees. Motor and sensory examination was normal bilaterally.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 0%, coded 5237 (lumbar spine strain), citing no tenderness, deformity, or spasm, and full ROM. The VA rated the low back condition 40%, coded 5243 (intervertebral disc syndrome (IVDS)), based on the 9 March 2004 C&P examination, citing thoracolumbar forward flexion of 30 degrees or less. Due to the likelihood of improvement, the assigned value was not considered permanent and was subject to future review (completed on 1 February 2005). Panel members noted the disparity in ROM measurements documented at the PT, NARSUM, and VA examinations. The CI’s back ROM waxed and waned with the degree of muscle pain or spasms, and the panel agreed that the March 2004 VA evaluation was an outlier and did not reflect the CI’s day-to-day functional ROM at the time of separation. Guarding associated with an abnormal gait and spinal contour was present on the PT and VA examinations most proximate to separation, and although this was an inconsistent finding, panel members concluded that there was sufficient reasonable doubt (§4.3) in favor of the CI to support a 20% rating (for guarding severe enough to result in an abnormal gait or spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis). There was no evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest for consideration under that alternate formula. While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty, and therefore an additional disability rating was not justified on this basis. 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 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	
Low Back Pain	5237	20%	

The following documentary evidence was considered:

AR20200004523,

Dear

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

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.

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