RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-05578 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20061208

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Small Arms and Light Artillery Repair, medically separated for “chronic low back pain” with a disability rating of 0%.

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 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 - 20061024	VARD - 20070410	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5243	0%	Lumbar Strain	5237	10%	20070206	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Chronic Low Back Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in May 2006 after lifting heavy equipment. An MRI on 10 May 2006 showed mild disc protrusion and spondylosis at L2-3/L3-4, mild stenosis at L4-5, and mild disc protrusion at L5-S1 without stenosis. At a physical therapy (PT) visit in June 2006, the provider found tenderness from L3-S1, but a normal gait and negative straight leg raise (SLR) tests. Thoracolumbar range of motion (ROM) revealed flexion to 60 degrees (normal 90), extension to 30 degrees (normal), and combined ROM greater than 120 degrees (normal 240). At the 20 July 2006 PT appointment, 5 months prior to separation, thoracolumbar flexion was to 30 degrees, with pain, and combined ROM was 145 degrees, after repetition. Except for lateral rotation, measurements were performed with an inclinometer.

The 4 August 2006 MEB NARSUM examination, 4 months before separation, noted complaints of constant low back pain associated with bilateral leg numbness and paresthesias as well as daily spasms. The examiner found no spinal abnormalities or tenderness, and axial/facet loading, SLR, and Faber tests were all negative. A week later, the MEB PT study showed flexion to 65 degrees, with painful motion, and combined ROM of 195 degrees, after repetition.

At the 6 February 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported burning, aching, and sharp mid to lower back pain with intermittent stiffness, but denied incapacitation. Physical examination revealed normal posture, gait, and spinal curvature, with no muscle spasm or evidence of radiating pain on movement. There was tenderness along the upper lumbar spine to the L4 level, minimal tenderness over the lower lumbar spine between L5-S1, and negative SLR testing bilaterally. Flexion was to 90 degrees, and combined ROM was 240 degrees, with painful motion, but no limitation due to fatigue, weakness, lack of endurance, or incoordination. Lumbar spine X-rays the same day showed no acute fracture or dislocation as well as normal disc spaces and vertebral body alignment.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 0%, coded 5243 (intervertebral disc syndrome (IVDS)), citing normal gait, no tenderness or spasm, and ROM limited by pain (with likely application of AR 635- 40, B-29, in effect at the time). The VA rated the low back condition 10%, coded 5237 (lumbosacral strain), based on the C&P examination, citing tenderness, painful motion and thoracolumbar flexion greater than 60 degrees but not greater than 85 degrees; or, combined ROM greater than 120 degrees but not greater than 235 degrees. Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion and/or combined ROM as reported on the MEB PT examination. Alternatively, a 10% rating was supported by painful motion recorded on all examinations 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 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 recommends a disability rating of 10% for the low back condition, coded 5243.

BOARD FINDINGS: In the matter of the low back condition, the panel recommends a disability rating of 10%, coded 5243 IAW VASRD §4.71a. There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5243	10%	

2	PD-2017-05578

DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY 251 18TH STREET SOUTH, SUITE 385
ARLINGTON, VA 22202-3531

AR20200004292, 

Dear XXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability. I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation. This will not result in any change to your separation document or the amount of severance pay. A copy of this decision will be filed with your Physical Evaluation Board records. I regret that the facts of the case did not provide you with the outcome you may have desired.

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 also been provided to the Department of Veterans Affairs.

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