RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04966
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Infantryman, medically separated for “lumbar back strain due to IED blast” with a disability rating of 10%.  

CI CONTENTION:  The VA rated higher for his conditions and the Army did not follow VA guidelines.  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 –20090316	VARD – 20080724	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Back Strain…	5237	10%	Degenerative Disc Disease [DDD] of the L4-L5 and L5-S1	5243	10%	STR	
Post Traumatic Stress Disorder [PTSD]  Secondary to IED Injury	Not Unfitting	PTSD	9411	50%	20080604	
Alcohol Abuse	Not Compensable	No VA Placement	
Post Concussive Headaches	Not Unfitting	Post-Concussion Syndrome with Atypical Migraine Headaches due to Traumatic Brain Injury	8045-8100	30%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Lumbar Back Strain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in December 2006 when his vehicle was struck by an IED blast and he sustained an impact injury to the lower back.  A lumbar spine MRI in March 2007 showed DDD and osteoarthritis with posterior disc bulges that mildly indented the anterior thecal sac with a superimposed small central protrusion at L4-5.  During the 11 May 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported low back pain.  Physical examination of the thoracolumbar spine revealed tenderness with no muscle spasm, and full active range of motion (ROM) with discomfort at the end point.  The 24 August 2007 MEB NARSUM examination, 5 months before separation, noted complaints of low back pain and physical findings from the DD Form 2808 were cited.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The EB rated the lumbar back strain condition 10%, coded 5237 (lumbar spine strain), citing tenderness IAW VASRD General Rating Formula for Diseases and Injuries of the Spine.  The VA also rated the low back condition 10%, coded 5243 (intervertebral disc syndrome), based on the STR, citing the non-ROM VASRD 10% criteria.  Although there was insufficient limitation of motion to support a 10% rating, members agreed a 10% rating was justified for the presence of tenderness and/or painful motion.  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.  

Contended PEB Conditions:  PTSD Secondary to IED Blast Injury; Alcohol Abuse; and Post Concussive Headaches.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting/not compensable.  There was no commander’s statement in evidence, but none of the conditions were profiled 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/compensability determination for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the lumbar back strain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended PTSD; alcohol abuse; and post concussive headaches conditions, the panel recommends no change from the PEB determinations as not unfitting/not compensable.  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.  

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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.

Sincerely,					      
Enclosure