RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX  	CASE:  PD-2017-05697
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080325

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Basic Trainee, medically separated for “chronic thoracic back pain” 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 - 20080306	VARD - 20080519	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Thoracic Back Pain	5235	10%	Residual Fractures, Thoracic Spine with Scoliosis and Loss of Normal Kyphosis	5235	20%	20080425	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Thoracic Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in August 2007 after falling while on an obstacle course.  On 7 December 2007, X-rays demonstrated loss of thoracic kyphosis in the mid-thoracic spine, T2 central concave deformity, and an anterior wedge compression deformity at T3.  Follow-up radiographs revealed no evidence of progression of the upper thoracic kyphosis.  

The 1 February 2008 MEB NARSUM examination, 1 month prior to separation, noted CI complaints of unimproved, continued back pain.  Physical examination showed normal posture and gait.  There was guarding but no muscle spasm, and spinal tenderness from T3-T6, but no paravertebral tenderness.  The examiner documented limited flexion and rotation to the right and left, but normal extension and lateral bending on both; axial loading and pelvic rotation were negative.  Thoracolumbar ROM measurements performed by physical therapy (PT) on 4 February 2008 showed flexion of 95 degrees (normal 90) and combined ROM of 230 degrees (normal 240) after repetition, with thoracic pain during right rotation and right lateral flexion.  There was no abnormal spinal contour.  

At the 25 April 2008 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported pain when sitting for prolonged periods without back support, and that she was unable to lift anything over 20 pounds; cold weather also aggravated the pain.  Physical examination showed a normal gait and no muscle spasm or ankyloses.  Thoracolumbar ROM revealed active flexion to 90 degrees and combined ROM of 220 after repetitive motion.  The examiner found the upper thoracic area was very tender with a moderate size kyphosis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5235 (vertebral fracture or dislocation), citing localized tenderness and guarding.  The VA rated the back condition 20%, also coded 5235, based on the C&P examination, citing pain on left lateral rotation, tenderness of the upper thoracic area with a moderate size kyphosis, and scoliosis probably associated with the CI’s condition.  Panel members agreed that while there was no limitation of thoracolumbar ROM to support a compensable rating under the General Rating Formula for Diseases and Injuries of the Spine, the NARSUM and VA examinations noted the presence of painful motion and localized tenderness, which warranted a 10% rating.  The panel noted that a moderate size kyphosis was present and scoliosis was recorded on the VA examination (although this was an inconsistent finding), and concluded that this was not a sufficient basis for a 20% rating (i.e. for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis).  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.  

BOARD FINDINGS:  In the matter of the 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.  

PD-2017-05697

AR20190008686, XXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXX

	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.

PD-2017-05697