RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04248
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty W2, CH-47 Pilot, medically separated for “chronic back pain” with a disability rating of 10%.   

CI CONTENTION:  No specific contention 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’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 - 20070622	VARD - 20071024	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5242	10%	Degenerative Disc Disease, Lumbar Spine 	5243	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in the summer of 1999 without specific injury or trauma.  An MRI from March 2007 revealed minor disc bulges at L4-L5 and L5 –S1, but at the May 2007 orthopedic spine consultation, the examiner did not recommend surgical intervention.  

During the 4 June 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the examiner found the active range of motion (ROM) was decreased in all planes secondary to pain, with the exception of forward flexion.  Strength, distal light touch and reflexes were intact.  The 5 June 2007 MEB NARSUM examination, 2 months prior to separation, noted complaints of pain exacerbated by lifting, bending, running, physical training, prolonged sitting or prolonged standing.  Physical examination showed a non-antalgic gait with no noted abnormalities.  There was “mild muscle spasms or tenderness to palpation in her lower back.”  Strength, reflexes and sensation were normal in the bilateral lower extremities.  Lumbar active ROM was decreased in all planes due to pain, except for forward flexion. She was able to touch her toes, but required using hands on the anterior thighs to stand up again.  

The 6 June 2007 physical therapy examination, 2 months prior to separation, noted complaints of 3/10 low back pain.  Physical examination showed no abnormal gait or spinal contour, but tenderness was present.  The ROM evaluation, after repetition, showed flexion of 130 degrees (normal 90) and combined ROM of 220 degrees (normal 240).  Flexion and extension measurements were assessed with an inclinometer except for side bending and rotation measurements, which were assessed with a goniometer.  

At the 9 January 2008 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported intermittent back pain with remissions.  The examiner found a normal gait and good posture.  There was no motor or sensory loss and reflexes were normal.  ROM measurements were flexion of 90 degrees and combined ROM of 180 degrees, with painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5242 (degenerative arthritis of the spine), citing ROM limited by pain with localized tenderness.  The VA also rated the back condition 10%, coded 5243 (intervertebral disc syndrome), based on the STR, citing evidence of muscle spasms in the lumbar spine and painful motion.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the physical therapy and C&P ROM examinations.  The panel noted an alternate rating of 10% was justified for tenderness, but this provided no rating advantage to the CI.  There was no muscle spasm or guarding severe enough 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.  

BOARD FINDINGS:  In the matter of the 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:

AR20180016670, 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.