RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-04367 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20090108

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

CI CONTENTION: Her back was worse than stated. Review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) was requested. 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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 – 20050504	VARD - 20051017	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-
5237	10%	L4-5 and L5-S1 Degenerative Disc Disease with a Small Central Disc Herniation at L5-S1	5242	10%	20090608	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

Chronic Low Back Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition started gradually in 2008 without specific injury or trauma to the back. X-rays showed spina bifida occulta, and an MRI revealed degenerative discs at L4-5 and L5-S1 with a non-encroaching L5-S1 disc protrusion.

The 30 July 2008 MEB NARSUM examination, 6 months prior to separation, noted complaints of back pain. Physical examination revealed lumbosacral spine active range of motion (ROM) was guarded with pain reproduced during forward flexion and rearward extension. There was some tenderness along the lumbosacral paraspinous region without palpable deformity or spasm. There was no evidence of visual or palpable deformity of the thoracolumbar or lumbosacral spine to include atrophy, hypertrophy or visible curvature. Physical therapy evaluation on 3 September 2008 recorded thoracolumbar ROMs as flexion to 80 (normal 90) degrees and combined ROM of 220 degrees (normal 240) which were equal for active and passive ROM.

At the 8 June 2009 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported low back fatigue, decreased motion, stiffness, weakness, spasms, and pain. Physical examination revealed thoracolumbar ROM with flexion of 70 degrees and combined ROM of 215 degrees with evidence of pain on active motion. There was evidence of guarding and tenderness. The CI’s gait and posture were normal. The examiner noted there were no incapacitating episodes.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), noting tenderness and citing flexion of 80 degrees. The VA also rated the back condition 10%, analogously coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of 70 degrees. 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 or combined ROM greater than 120 degrees but not greater than 235 degrees, as reported on all examinations proximate to separation. 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 neck condition.

BOARD FINDINGS: In the matter of the lumbar degenerative disc disease 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:

AR20200000180, XXXXXXXXXXXXXXXXXXXXXX 

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.