RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXX	CASE: PD-2017-04239
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20091005

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Wheeled Vehicle Mechanic, medically separated for “spinal fusion” with a disability rating of 20%.

CI CONTENTION:  “Review all conditions.”  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 - 20090612	VARD - 20100406	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Spinal Fusion, L4-L5	5241	20%	Degenerative Disc Disease Lumbar Spine	5243	20%	20091214	
Bilateral Knee Pain	Not Unfitting	Right Knee Degenerative Joint Disease	5010	10%	20091214	
		Left Knee Degenerative Joint Disease	5010	10%	20091214	

Bilateral Shoulder Pain	Not Unfitting	Left Shoulder Impingement Syndrome with Tendonitis	5201	20%	20091214	
		Right Shoulder Impingement Syndrome with Tendonitis	5201	20%	20091214	
Bilateral Hip Pain	Not Unfitting	Right Hip Degenerative Joint Disease	5010	10%	20091214	
		Left Hip Degenerative Joint Disease	5010	10%	20091214	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 80%	

ANALYSIS SUMMARY:

L4-5 Spinal Fusion. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s longstanding back condition was aggravated while in Iraq in 2006, and treatment included anti-inflammatory medication and muscle relaxants. In February 2008, he reported a sudden onset of back pain with lower extremity radiculopathy, and was found to have a ruptured disc at L4-5. He underwent a discectomy in April 2008, and due to failed recovery and continued symptoms, he had a repeat surgery in May 2008. In October 2008, he underwent a spinal fusion. During the 7 May 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the examiner documented decreased range of motion (ROM). The MEB NARSUM examination, the same day, noted complaints of pain aggravated by prolonged

sitting, standing, or laying in one position, as well as walking long distances or bending. Physical examination showed an antalgic gait and guarding secondary to pain, but normal spinal curvature. Flexion was to 50 degrees (normal 90) and combined ROM was 165 degrees (normal 240), with limitation due to pain. Sensory, motor and deep tendon reflexes were intact. At the 14 December 2009 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant pain with radiation while sitting. He had daily pain flare-ups, but no incapacitating episodes, and flexion was to 40 degrees with a combined ROM of 115 degrees.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 20%, coded 5241 (spinal fusion), citing limited forward flexion. The VA also rated the low back condition 20%, but coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P examination, citing thoracolumbar flexion greater than 30 degrees but not greater than 60 degrees. Panel members agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on the NARSUM and C&P examinations. There was no evidence of IVDS to support a higher rating under that alternate 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 low back condition.

Contended PEB Conditions: Bilateral Knee Pain, Bilateral Shoulder Pain, and Bilateral Hip Pain. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. None of the conditions were profiled or implicated in the commander’s statement, and did not fail retention standards. There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the low back condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication. In the matter of the contended bilateral knee pain, shoulder, and hip pain, the panel recommends no change from the PEB determinations as not unfitting. 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:

2	PD-2017-04239

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

AR20200000162, 

Dear XXXXXXXXXXXXXX

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.