RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04465
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071024

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Wheeled Vehicle Mechanic, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:  “My back has only gotten progressively worse and does not allow me to work.”  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 - 20070717	VARD - 20080528	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5239	10%	Spondylolysis, L5-S1	5003-5242	10%	20080207	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI reported in March 2007 a one and a half year history of back pain that began after multiple road marches.  Radiographic studies in 2007 showed bilateral L5 pars defect with no evidence of spondylolisthesis or stenosis.  

At the primary care clinic on 22 February 2007, the CI reported lower 2/10 back pain.  Physical examination revealed full thoracolumbar range of motion (ROM) with pain, tenderness and spasm.  Gait and stance were normal.  During the May 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported no back problems until he began basic training.  Physical examination revealed decreased flexion and tenderness, but was otherwise normal.  The 13 June 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of severe back pain even with minimal activity (rated as 3/10 at examination).  He was unable to do push-ups or sit-ups or wear his rucksack or body armor without severe lower back pain.  Physical examination showed normal gait and strength.  Goniometric ROM testing showed flexion of 90 degrees (normal) and combined ROM of 225 degrees (normal 240), with pain on lateral flexion.  There was tenderness and muscle spasms in the lumbosacral area.  

At the 7 February 2008 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported constant pain in the lower back, more severe with bending, prolonged standing or walking.  Activities of daily living were affected, but there were no lost days due to incapacitation.  Physical examination showed a normal gait.  The ROM study showed forward flexion of 80 degrees, with pain, and combined ROM of 230 degrees.  There was no loss of motion due to pain, fatigue, weakness or lack of endurance after repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5239 (spondylolisthesis or segmental instability), citing tenderness and spasm.  The VA rated the back condition 10%, analogously coded 5003-5242 (degenerative arthritis of the spine) based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees.  

The panel agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on all examinations proximate to separation or limitation of flexion (greater than 60 degrees but not greater than 85 degrees) as reported on the VA C&P examination proximate to separation.  Although there was muscle spasm as noted in the NARSUM, it was not 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:

AR20180014215, 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.