RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX		CASE: PD-2017-04344 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20090127

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “low back pain (LBP)” with a disability rating of 10%.

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’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 - 20081126	VARD - 20090622	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LBP	5299-5242	10%	Lumbar Strain with Sixth Vertebrae Sacralization…	5237	10%	20090227	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

LBP. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s low back condition began in May 2006 in Iraq without any known trauma to his spine. He initially had a sore back that occurred while he was wearing body armor on patrols. MRI of the lumbar spine on 24 March 2008, 10 months prior to separation, revealed transitional anatomy at the lumbosacral junction with a transitional vertebra, which the examiner believed was a partially sacralized L5 disc on the right side. There was also a fusion anomaly at the same level. There was no evidence of focal disc protrusion or significant canal or neural foramina stenosis at any level within the lumbar spine.

At the time of the orthopedic clinic appointment on 20 August 2008, 5 months prior to separation, the CI reported back pain (4/10) that got worse with casual lifting and running. On examination the lumbosacral spine exhibited a normal appearance and the CI’s gait and stance were normal. Thoracolumbar range of motion (ROM) was normal in all planes. There was tenderness in the L5 area. Straight leg raise (SLR) test and Waddell’s tests were both negative and there were no muscle spasms.

During the 10 September 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported LBP. Physical examination revealed tenderness in the bilateral subscapular areas and mid upper back. Thoracolumbar ROM measurements performed by physical therapy (PT) on 22 September 2008, 4 months prior to separation, showed flexion of 90 degrees (normal) and combined ROM of 230 degrees (normal 240) after repetition. The 18 November 2008 MEB NARSUM examination, 2 months prior to separation, noted complaints of 3/10 LBP that flared to 8-9/10 when he lifted objects heavier than 30 pounds or when he ran. Focused physical examination on 27 October 2008 showed full ROM in the lower back with some left rotation of the spine noted when he flexed forward. He complained of pain in the lower back at the extreme of flexion. There was no tenderness. SLR testing was negative and no Waddell’s signs were present. Strength was 5/5 and reflexes were intact, normal and symmetric.  Standard gait, tandem and heel and toe walking were normal.

At the 27 February 2009 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported LBP with flare-ups at random times, usually associated with stiffness which flared up after prolonged sitting or standing. He complained of tenderness in the low back with occasional spasm. He reported there was no sciatica and no incapacitating episodes. Physical examination showed SLR testing was negative bilaterally and there was no spasm, incoordination, fatigue, or weakness. Deep tendon reflexes were 2+ and symmetrical in the lower extremities and 1+ in the upper extremities. Gross motor and sensory examination was normal and there was no numbness, weakness or atrophy of the lower extremities. Thoracolumbar ROM showed flexion of 90 degrees and combined ROM of 230 degrees with painful motion noted at the extreme of range of motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 10%, analogously coded 5242 (degenerative arthritis of the spine), citing painful motion in the face of preserved ROM at the minimal compensable level. The VA also rated the low back condition 10%, coded 5237 (lumbosacral strain), based on the C&P examination, citing medical evidence of painful limitation of motion in the spine with combined ROM of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.

The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the PT and VA C&P examinations proximate to separation. The painful motion also warranted a 10% rating. 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 low 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:
PD-2017-04344 

AR20190012184, XXXXXXXXXXXXXXXXXXXXXX 

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.