RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXXX	CASE: PD-2017-04955
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20050530

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Aerial Intelligence Specialist, medically separated for “back pain” with a disability rating of 10%.

CI CONTENTION:  Review all conditions.  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 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 - 20050418	VARD - 20070306	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain	5237	10%	Back Pain due to Congenital Spina Bifida Occulta	5237	20%	20050720	
Recurrent Right Knee Pain	Not Unfitting	History of Pellet Wound, to Right Knee	5257	NSC	20050720	
Occasional Heart Palpitations	Not Unfitting	Heart Palpitations	7011	NSC	20050720	
Recurrent Tinea Pedis	Not Unfitting	Recurrent Tinea Pedis	7813	NSC	20050720	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Back Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in basic training and worsened in March 2003 after physical exertion, but without any specific injury or trauma. A December 2004 MRI showed minor disc bulging at L4-5 and L5-S1; surgical intervention was not indicated. The 5 April 2005 MEB NARSUM examination, 2 months before separation, noted complaints of constant low back pain aggravated by repeated bending, heavy lifting, standing more than 15 minutes, running or impact activities. The examiner noted tenderness but no spasm or visible deformity, and lumbar goniometric range of motion (ROM) measurements showed flexion of 80 degrees (normal 90) and combined ROM of 225 degrees (normal 240), with pain in all planes.

At the 20 July 2005 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant back pain, rated at 5-7/10, with flare-ups after prolonged standing,

lifting, pushing or shoving. Physical examination showed tenderness but a normal gait. Forward flexion was to 60 degrees and combined ROM was 175 degrees, with discomfort throughout.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing flexion limited to 80 degrees and paraspinal tenderness. The VA also rated the back condition 10%, coded 5237, based on the C&P examination, citing VASRD ROM criteria for a 10% evaluation using the General Rating Formula for Diseases and Injuries of the Spine. Panel members noted the variation in the NARSUM and VA forward flexion measurements. Muscle spasms were present during the VA examination, which could reasonably account for the decreased ROM, and thus the panel placed higher probative value on the NARSUM examination as indicative of the CI’s functional ROM at the time of separation. Panel members 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 combined ROM (greater than 120 degrees but not greater than 235 degrees). 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. 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: Right Knee Pain, Occasional Heart Palpitations and Recurrent Tinea Pedis. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. None of the conditions were profiled or implicated in the commander’s statement, and did not fail retention standards. There was no performance- based evidence from the record that any 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 any 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 right knee pain, occasional heart palpitations and recurrent tinea pedis, 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.

2	PD-2017-04955

XXXXXXXXXXXXXXX:

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.

Sincerely,

Enclosure