RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04540
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090708

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Signal Support Systems Specialist, medically separated for “degenerative arthritis of the spine” with a disability rating of 10%.   

CI CONTENTION:  Review all conditions.  The CI also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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’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 - 20080225	VARD - 20090825	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis of the Spine	5242	10%	DDD, Lumbar Spine 	5242	10%	20090527	
GERD	Not Unfitting 	No VA Placement	
Hyperlipidemia			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60% 	

ANALYSIS SUMMARY:  

Degenerative Arthritis of the Spine.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in 1992 after being hit by a car and was aggravated in July 2007 after falling while wearing battle gear.  X-rays in May 2008 showed bilateral L5 spondylolysis with associated spondylolisthesis (sliding of a vertebra on the one below it) of L5 on S1.  An MRI of the lumbar spine in June 2008 showed degenerative disc disease (DDD) at L4-5 and L5-S1 without herniation, but with probable foraminal compromise at L5-S1.  

At a physical therapy appointment on 18 June 2008, the range of motion (ROM) study showed extension decreased by 50% (normal 30 degrees); right side bending decreased by 25% (normal 30 degrees) with pain; and left lateral rotation was decreased by 25% (normal 30 degrees) with pain.  There was tenderness and the gait was forward leaning (unable to stand straight due to slight hip flexion), but heel-to-toe walk was within normal limits. 

During the orthopedic visit on 30 September 2008, the CI reported worsening back pain radiating into his left leg down to his toes.  On examination, he had tenderness.  The ROM study showed flexion of 50 degrees (normal 90) and combined ROM of 120 degrees (normal 240).  Motor and sensory tests were normal except there was slight decrease on the lateral aspect of the left calf.

At the 15 October 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported back pain that sometimes awakened him at night and left leg pain and numbness.  The CI had a normal spine evaluation.   The 20 January 2009 MEB NARSUM examination, 6 months prior to separation, noted complaints of chronic 7-8/10 low back pain 80% of the time when awake deterring his ability run, walk for long distances or stand for a prolonged periods of time.  Physical examination showed no spasm or spinal deformity and straight leg raising (to determine nerve root pain) was negative.  Gait and posture were normal and there were no motor or sensory deficits.  The ROM evaluation showed flexion of 80 degrees and combined ROM of 230 degrees, with pain in all planes except left lateral flexion.  

At the 26 May 2009 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported a dull paresthesia-like feeling from the hips to the thighs, but no typical pain to suggest any acute radiculitis clinically.  He had no bowel or bladder problems.  Physical examination showed a normal gait and no spasm.  The ROM study revealed flexion of 70 degrees and combined ROM of 185 degrees after repetition with pain in all planes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), citing forward flexion of 80 degrees.  The VA also rated the back condition 10%, coded 5242, 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 noted that although the ROM measurements were recorded as lumbar, the fact that flexion easily exceeded 60 degrees on both the MEB NARSUM and VA C&P examinations, the measurements were most-likely thoracolumbar.  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) as reported on the most probative examinations proximate to separation (MEB NARSUM and VA C&P).  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.  

Contended PEB Conditions:  GERD (Gastroesophageal Reflux Disease) and Hyperlipidemia.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  Neither of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either 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 either of the contended conditions, so no additional disability ratings are recommended.  
BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended GERD and hyperlipidemia conditions, 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:

[AR Number], XXXXXXXXXX
. 
Dear XXXXXXXXXX:

	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.