RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-05377 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20091127

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

CI CONTENTION: The CI requested review of all conditions to include additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) was also requested. 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 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 - 20090826	VARD - 20100906	
Condition	Code	Rating	Condition	Code	Rating	Exam	
IVDS Thoracolumbar Spine	5243	10%	IVDS Lumbar Spine	5243	0%	20100316	
Bilateral Pes Planus	Not Unfitting	Bilateral Plantar Fasciitis	5276	0%	20100316	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 70%	

ANALYSIS SUMMARY:

Thoracolumbar Spine IVDS. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in March 2007 after jumping off a truck with a full pack. A lumbar spine MRI taken in April 2009 showed a small disc protrusion with annular tear at L5-S1 with narrowing of the lateral recess and possible contact of the left S1 nerve root. Surgery was recommended, but the CI reasonably opted for conservative treatment.

The 29 June 2009 MEB NARSUM examination, 5 months prior to separation, noted complaints of constant burning low back pain which precluded prolonged sitting or standing. Physical examination showed a normal gait and spinal contour. There was spinal tenderness, but no muscle spasm. Repetitive-goniometric thoracolumbar forward flexion was 90 degrees (normal) and combined range of motion (ROM) was 230 degrees (normal 240) with painful motion. Motor strength, sensation and reflex testing were all normal.

At the 16 March 2010 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported throbbing back pain that went up the back to the neck. Physical examination revealed an antalgic gait due to the CI’s pregnancy. There was no spinal tenderness, spasm or guarding. A back ROM study was not addressed.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5243 (IVDS), citing limitation of motion. Using the same code, the VA rated the back condition 0%, based on the C&P examination, citing the physical examination did not reveal any evidence of muscle spasm, guarding or tenderness, and ROM could not be evaluated due to pregnancy.

The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM greater than 120 degrees but not greater than 235 degrees, as reported on the MEB NARSUM examination. 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 IVDS 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 Condition: Bilateral Pes Planus. The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. The contended condition was not profiled or implicated in the commander’s statement, and did not fail retention standards. There was no performance-based evidence from the record that the condition 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 the contended condition, so no additional disability rating is 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 bilateral pes planus condition, the panel recommends no change from the PEB determination 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-2017-05377

ARXXXXXXXXXXX 

Dear XXXXXXXXXXXXXX:

	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,