RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05415
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090802

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Cavalry Scout, medically separated for “back pain evaluated as lumbosacral strain” 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’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 - 20090423	VARD - 20100309	
Condition	Code	Rating	Condition	Code	Rating	Exam	
…Lumbosacral Strain	5299-5237	10%	Lumbosacral Strain with Spondylosis and Schmorl's Nodes	5237	10%	20100203	
Cervicalgia	Not Unfitting	Cervical Strain	5237	10%	20100203	
Hyperlipidemia	Not Unfitting	High Cholesterol	7799-7716	NSC	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI was first seen in April 2008 for low back pain associated with normal activities and no specific trauma.  The pain persisted despite conservative treatment.  Lumbosacral X-rays on 22 December 2008 were normal, and an MRI on 16 January 2009 showed multilevel Schmorl’s nodes (congenital condition), but was otherwise unremarkable.  In primary care evaluations 1 week and 1 month later, the CI had full, painful range of motion (ROM).  He reported left lower extremity numbness, but electro-diagnostic testing on 20 March 2009 showed normal results.  He was not considered a candidate for steroid injections or surgery.

During the 17 March 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported back problems since April 2008.  Physical examination showed tenderness and spasm with painful movement, but ROM was not recorded; neurological findings were normal.  The 6 April 2009 MEB NARSUM examination noted the above history, and the examiner documented mild spasm and a normal neurological examination.  Measured ROM showed flexion of 70 degrees (normal 90) and combined ROM of 200 degrees (normal 240).  

At the 3 February 2010 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported low back pain from cumulative trauma, but denied incapacitation.  Physical examination showed a normal gait and neurological findings.  Flexion was 75 degrees and the combined ROM was 175 degrees.  Tenderness was present, but spasm not recorded.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, analogously coded 5299-5237 (lumbar spine strain), citing limitation of motion.  The VA rated the low back condition 10%, coded 5237, based on the C&P examination, citing painful and limited motion.  Members agreed that 10% rating, but no higher, was supported by MEB and VA evidence of tenderness and painful, limited motion.  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:  Cervicalgia and Hyperlipidemia.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  Neither condition was profiled nor implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that either 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 either of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended cervicalgia and hyperlipidemia, 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.  

The following documentary evidence was considered:

AR20190006174, 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.