RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05236
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20090127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Infantryman, medically separated for “Chronic low back pain, associated with bilateral L4 pars defects” with a disability rating of 20%.  

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 PEB, but determined 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.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to 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 (VA), operating 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 the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20080918	VARD - 20090805	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain, Associated With Bilateral L4 Pars Defects, Evaluated
As Vertebral Fracture	5235	20%	Degenerative Disc Disease Lumbar Spine With Bilateral Pars Defect, L4-5, L5-S1	5242	10%	20081126	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Chronic Low Back Pain, Associated With Bilateral L4 Pars Defects, Evaluated As Vertebral Fracture.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in May 2006 after another soldier fell on him while conducting physical training.  At the 13 April 2007 primary care appointment, the CI reported sharp back pain that radiated anterior through his ribs and down to the lower abdomen areas.  Pain was reported as 8-9/10 in severity.  Examination showed tenderness to palpation (TTP) at the L3-L4 midline with paraspinal spasm greater on the left than right.  ROM was full with pain noted.  Straight Leg Raise (SLR) testing was normal.  At the 14 April 2007 physical therapy (PT) appointment, the examiner noted a significant amount of lumbar paraspinal spasm and that the symptoms were due to S1 and thoracic dysfunctions.  

During the 16 April 2007 PT appointment, examination showed the S1 misaligned with mild to moderate spasm of the upper lumbar and lower thoracic region.  There was some sign of improvement from the previous visit.  At the 6 February 2008 PT appointment, examination of the lumbosacral spine showed lordosis with TTP of the spinous process on the left.  Both sides of the lumbosacral spine exhibited TTP of the transverse process at left.  Lumbosacral spine pain was elicited by action flexion of 15 degrees.  There was no swelling, ecchymosis or asymmetry. The lumbosacral spine indicated a normal curvature with no muscle spasms and demonstrated full ROM without exceptions.  SLR testing was negative.  X-rays on 3 April 2008 showed bilateral L4 pars defects present, but the lumbar spine was normally aligned.  There was no fracture, focal osseous lesion, or degenerative changes noted.  Both the sacrum and sacroiliac joints were normal.  The CI was diagnosed with bilateral L4 pars interarticularis defects without spondylolisthesis.  

The 31 July 2008 MEB NARSUM examination, 6 months prior to separation, noted complaints of low back pain.  Physical examination showed a gait that was not antalgic and an ability to arise easily from the chair to the examination table.  There was mild TTP in the lower lumbar spine at L4 on the midline with no palpable spasm or sciatic notch tenderness.  SLR testing was negative bilaterally for radiating symptoms and motor exams were 5/5 throughout.  The examiner referenced the thoracolumbar ROM measurements performed by PT on 7 July 2008 with a goniometer (6 months prior to separation) which recorded active flexion to 40 degrees (normal 90), extension 10 degrees (normal 30), right lateral flexion 10 degrees (normal 30), left lateral flexion 5 degrees (normal 30), right rotation 30 degrees (normal 30), left rotation 45 degrees (normal 30) for combined ROM of 209 degrees (normal 240).  The CI reported pain on most days at 4-5/10 in severity, and at its worst a 7-8/10.  The pain was described as a tight ache in his lower lumbar spine that “radiated around his abdomen with sharp spikes of pain.”  He reported occasional pain in his right buttock, but no radicular symptoms were noted by the examiner.  The pain was aggravated by twisting, bending and heavy lifting which occasionally interfered with sleep.  He could lift up to 30-40 pounds without aggravating the pain and he could walk a mile at his own pace.  He took Tramadol for pain control and could perform activities of daily living.  The CI was diagnosed with chronic low back pain with bilateral L4 pars defect.  

During the 26 August 2008 primary care appointment, the examiner noted a lumbosacral spine ROM flexion of 90 degrees with pain.  The pain was elicited at the extreme limits of the ROM.  An SLR test was positive on left.  There were no lumbosacral spinal muscle spasms.  MRI studies on 2 September 2008 showed stable bilateral spondylolysis at L4 with normal intervertebral disc spaces from L1 through L4.  At the L5-S1 there was posterior disc bulge without neural foraminal or central canal stenosis.  There was a posterior disc bulge at L4-L5 resulting in severe left and moderate right neural foraminal stenosis and moderate central spinal canal stenosis.  During a 17 September 2008 primary care appointment, lumbar ROM measurements recorded active flexion to 45 degrees, extension 30 degrees, right lateral flexion 25 degrees, left lateral flexion 20 degrees, right rotation 30 degrees, left rotation 30 degrees and combined ROM of 180 degrees.  Functional loss of ROM was at 40 degrees flexion, 25 degrees left rotation, and 30 degrees right rotation.  All measurements were performed with a goniometer.  

At the 26 November 2008 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported a history of low back pain and had been treated previously with bed rest for a month following the injury.  He then wore a back brace for 3 months.  The CI also complained of spasms, and sharp daily pain that lasted for hours which radiated around the lower ribs.  Physical examination showed the CI with sharp, moderate pain with stiffness.  There was no evidence of intervertebral disc syndrome (IVDS) and no reports of incapacitating episodes.  ROM recorded active flexion to 85 degrees, extension 30 degrees, right lateral flexion 30 degrees, left lateral flexion 30 degrees, right rotation 30 degrees, left rotation 30 degrees.  Pain began at 50 degrees forward flexion and 30 degrees of lateral flexion left and right.  There was no additional loss of motion with repetitive motion.  There was no objective evidence of muscle spasm, atrophy, guarding, or weakness.  Posture, head position, and gait were normal.  There were no abnormal spinal curvatures and sensory testing of the lower extremities were normal.  Motor exam and deep tendon reflexes were also normal.  X-ray studies demonstrated degenerative disc disease and changes at L4-5 and L5-S 1 bilaterally, and bilateral L4 pars interarticularis defects.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain condition 20%, coded 5235 (vertebral fracture or dislocation), citing functional impairment, painful motion and functional loss.  The VA rated the low back pain condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 2 months before separation, citing forward flexion.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees), as reported on the MEB NARSUM, primary care and PT examinations.  There was no evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back pain condition.  

BOARD FINDINGS:  In the matter of the low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170627, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180000804, 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.

Sincerely,					      
Enclosure