RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-05953
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Combat Engineer, medically separated for “chronic low 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 - 20061003	VARD - 20070216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Degenerative Disc Diseases of the Thoracolumbar Spine	5242	10%	20070124	
Chronic Headaches Status Post Aseptic Meningitis	Not Unfitting	Migraine Headaches, Status Post Meningitis	8100-8019	10%	20070124	
Status Post Lyme Disease	Not Unfitting 	Lime Disease	6319	0%	20070124	
Vasomotor Rhinitis/Perennial Allergic Rhinitis	Not Unfitting	Allergic Rhinitis	6522	0%	20070124	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s low back condition began in July 2003 when he reported lateral numbness to the left leg and low back pain associated with a spinal tap from 10 weeks earlier.  Lumbosacral X-rays were normal, but an MRI in December 2004 revealed a small right paracentral disc protrusion at T11-12, a small annular tear in the central aspect of the disc annulus at L5-S1, and a minimal disc bulge at L4-5 with minimal impression of the anterior aspect of the thecal sac; no spinal cord impingement was noted.  A neurologist diagnosed degenerative disc disease and proceeded with pain management injections and physical therapy.  A lumbosacral myelogram CT scan in April 2005 and a discogram in May 2005 were normal, and a pain specialist assessed “lumbosacral spondylosis without myelopathy.” A lumbosacral MRI in March 2006 revealed a small bulging disc at L5-S1 with no significant mass effect, and in April 2006, a spine specialist diagnosed “low back pain…with mild arachnoiditis suggested on MRI.”  Surgical intervention was not indicated.  During the 19 June 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported persistent back problems and was not able to wear load bearing gear.  Physical examination showed tenderness with spasm and decreased range of motion (ROM).  

The 6 July 2006 physical therapy examination, 4 months before separation, noted complaints of low back pain.  The provider noted normal posture, no muscle spasms, negative straight leg raising, and no lower extremity weakness.  Goniometrically measured ROM showed flexion to 70 degrees (normal 90) and a combined ROM of 205 degrees (normal 240), with painful motion.  During the 28 August 2006 MEB NARSUM examination, 2 months prior to separation, the CI complained of low back pain, rated at 1-2/10 and increased to 4/10 during physical activities, but denied bladder or bowel dysfunction.  He also had intermittent numbness when running or performing strenuous physical activity.  Physical examination showed normal gait and stance with intact heel and toe walking.  There was localized tenderness to the spinal processes from L3-S1 and painful motion (not quantified), but spinal rhythm was normal with no kyphosis, scoliosis and no muscle spasm.  Neurologic examination was normal to include:  strength, sensation, reflexes and negative straight leg raising, bilaterally.  

At the 24 January 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported sharp pain, rated at 4/10, across the lumbar spine with occasional radiation up to the thoracic spine.  The pain was aggravated by standing too long and picking up heavy objects, and relieved by relaxing.  Physical examination showed moderate slouching, normal gait/spinal curvature, and no muscle spasm, guarding or tenderness present.  Flexion was to 95 degrees and combined ROM was 240 degrees, with pain.  

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 (spinal stenosis) citing tenderness and loss of spinal motion attributed to pain with no muscle spasm.  The VA also rated the low back condition 10%, but coded 5242 (degenerative arthritis of the spine) based on the C&P examination, citing functional impairment resulting from painful thoracolumbar flexion, extension, and bilateral rotation.  Panel members agreed that although there was insufficient limitation of motion to support a compensable rating, a 10% rating was justified for the presence of painful motion and tenderness.  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.  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 chronic low back pain condition.  

Contended PEB Conditions:  Chronic Headaches Status Post Aseptic Meningitis, Status Post Lyme Disease, and Vasomotor Rhinitis/Perennial Allergic Rhinitis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that any 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 any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  In the matter of the contended chronic headaches status post aseptic meningitis, status post Lyme disease, and vasomotor rhinitis/perennial allergic rhinitis, 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.  

ARXXXXXXXXXX, XXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXX:

	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,					      

Enclosure