RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX		CASE: PD-2017-05687 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20051011

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

CI CONTENTION: No specific contention was made. 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 – 20050801	VARD – 20060315	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5243	10%	Degenerative Disc Disease, Lumbosacral Spine	5003	10%	20060130	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Low Back Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent an L5-S1 lumbar discectomy, laminotomy, and foraminotomy with right S1 nerve root decompression in July 2004. After experiencing temporary relief, radiation returned into the right leg within months, and the CI declined an offer for a repeat surgery.

During the 10 May 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the examiner noted tenderness along the paraspinal muscles from T12-L5. Station and gait were normal, and the CI was able to heel, toe and duck walk without problems. The 8 June 2005 MEB NARSUM examination noted complaints of constant pain, rated at 8/10, but no numbness or tingling. Physical examination showed a normal gait and tenderness over the paraspinal muscles on the right from T12-L5, and the remaining findings were normal. The 14 June 2005 MEB physical therapy (PT) range of motion (ROM) evaluation, 4 months before separation, showed active flexion to 75 degrees (normal 90) and combined ROM of 205 degrees (normal 240), after repetition and with no painful motion.

At the 30 January 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported daily back pain with radiation to the right thigh, rated at 8/10. Physical examination showed no tenderness or spasm, and flexion was to 90 degrees with a combined ROM of 240 degrees, with pain on flexion. After repetitive motion, there was no additional limitation due to pain, weakness, fatigability, incoordination, lack of endurance or flare-ups. There were no incapacitating episodes in the past year that required visits to the emergency room or hospitalization.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 10%, coded 5243 (intervertebral disc syndrome (IVDS)), citing flexion of 80 degrees. The VA also rated the low back condition 10%, but coded 5003 (arthritis, degenerative), based on the C&P examination, citing degenerative disc disease of the lumbosacral spine. Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB PT 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 low back condition.

BOARD FINDINGS: In the matter of the low back condition 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.

2	PD-2017-05687
XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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.