RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05192
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Military Policeman, medically separated for “mid-thoracic back pain” with a disability rating of 10%.  

CI CONTENTION:  Review requested of additional conditions (post traumatic stress disorder and traumatic brain injury) 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 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 – (date not in record)*	VARD - 20070808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mid-Thoracic Back Pain*	--*	10%	Thoracic Degenerative Disease	5237	0%	20070601	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	
*MEB condition used as DA Form 199 not in evidence and not available

ANALYSIS SUMMARY:  

Mid-Thoracic Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s mid-thoracic back pain began in August 2004 while serving as a gunner during a deployment.  He was thrown from his vehicle when it went off the road, and he hit his back on the turret and lost consciousness for 2 minutes.  He was involved in a second motor vehicle accident on 8 October 2004 and had a sharp pain in the middle of his back thereafter.  Treatment records documented full range of motion (ROM) with pain in the right rhomboid, trapezius, and infrascapular areas, and treatment with a nonsteroidal anti-inflammatory drug, pain reliever and muscle relaxer.  

At a physical therapy (PT) visit on 2 June 2005, the CI reported chronic back pain for 8 months.  The provider noted lower thoracic and lumbosacral tenderness over the spinous processes, and active flexion and extension “decreased 50%” due to pain; X-rays showed very mild thoracic spine degenerative changes, but no fracture.  While PT was ongoing, the CI was seen in family practice on 12 September 2005 and treated with tramadol (opioid-like medication) and cyclobenzaprine (muscle relaxant).  At a PT appointment on 21 September 2005, he had full ROM with tenderness along the thoracic spine, and during an 18 October 2005 visit, he indicated an actual increase in back pain after the rehabilitation sessions.  On 5 December 2005, a primary care provider noted normal gait and posture, no thoracic or lumbosacral spine tenderness or muscle spasms, and negative straight leg raising (to determine nerve root irritation); a combination narcotic/pain reliever medication was prescribed.  An MRI on 14 December 2005 demonstrated a minimal posterior disc bulge with canal stenosis at the T8-9 level compatible with mild degenerative disc disease.  At a primary care follow-up on 3 January 2006, the CI’s gait and stance were normal with no tenderness, muscle spasms or abnormalities noted.  

During the 21 March 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported daily mid and lower back pain.  Physical examination revealed mid thoracic spine tenderness and pain during thoracolumbar ROM.  The 7 April 2006 MEB NARSUM examination, 3 months before separation, noted CI complaints of back pain.  A focused back and neurologic evaluation showed normal thoracic and lumbosacral spine findings, except for mid thoracic spine tenderness and pain during ROM measurements.  Straight leg raising was negative and gait and stance were normal.  Measured ROM, using an inclinometer, showed flexion to 85 degrees (normal 90), with a combined ROM of 190 degrees (normal 240), and moderate pain during motion. 

At the 1 June 2007 VA Compensation and Pension (C&P) examination, 11 months after separation, the CI reported back pain.   Physical examination showed no spinal tenderness except at T7-T8, and there was no step off or objective evidence of spasm, fatigue, or weakness.  Flexion was to 90 degrees and combined ROM to 240 degrees, without pain or limitation with repetition.  The examiner’s diagnosis was thoracic degenerative disease based on an MRI that showed a mild T8-T9 disc bulge with mild degenerative changes.  At a VA examination on 13 June 2007, the CI had thoracic paraspinal tenderness and X-rays were normal.  At a VA clinic appointment on 3 July 2007, 12 months after separation, the CI reported he was employed full-time and had mid back pain which was worse after a full workday.  Gait was normal and there was no tenderness. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the mid-thoracic back pain 10%, but in the absence of a DA Form 199, the code and rating explanation were unknown.  The VA rated the thoracic degenerative disease 0%, coded 5237 (lumbosacral strain), based on the C&P examination, citing a noncompensable evaluation for thoracolumbar forward flexion greater than 85 degrees or combined ROM greater than 235 degrees.  Members agreed that a 10% rating, but no higher, was justified for limitation of motion as reported on the NARSUM examination which was most 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 mid-thoracic back pain condition.  

BOARD FINDINGS:  In the matter of the mid-thoracic back pain 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.  

AR20190005622, XXXXXXXXXXXXXXXXXX

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.

A copy of this decision has been provided to the counsel you listed on your application,