RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2017-06080
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050415

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

CI CONTENTION:  Review of post-traumatic stress disorder was requested though it was not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20050321	VARD - 20060609	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracic Back Pain	5237	10%	Scheuermann Disease of the Thoracic Spine 	5299-5239	20%	20050922	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Thoracic Back Pain.  According to the service treatment record, the CI’s back condition began in September 2000 after heavy lifting.  He reinjured his back in November 2003 in a motor vehicle accident.  An MRI in July 2004 showed multi-level thoracic disc space narrowing with diffuse desiccation (drying out).  Electrodiagnostic studies of the lower extremities in January 2005 were normal.  There was no surgical indication.

The 16 November 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of low back pain.  Physical examination showed a normal gait, but spinal tenderness and spasm were not addressed.  The MEB range of motion (ROM) study was performed by physical therapy (PT) on 13 December 2004, 4 months before separation.  Repetitive flexion was 90 degrees (normal) and combined ROM was 220 degrees (normal 240) with painful motion.

At the 22 September 2005 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported progressively worsening back pain.  Physical examination showed a normal gait and good posture, but there was mild thoracic spine tenderness and back spasm without guarding.  Thoracolumbar flexion was 70 degrees and combined ROM was 205 degrees with painful motion.  Combined ROM decreased to 195 degrees following repetitive motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral spine strain), citing painful motion and spinal tenderness.  The VA rated the thoracic back condition 20%, analogously coded 5299-5239 (spondylolisthesis or segmental instability), based on the C&P examination, citing limitation of motion.  The panel agreed that a 10% rating, and no higher, was warranted for limitation of flexion or combined ROM based on the pre-separation PT ROM examination and the post-separation VA examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus a higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome 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 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-2017-06080

ARXXXXXXXXXXX, XXXXXXXXXXXXXXXXXXXX 

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.

Sincerely,					      

Enclosure

	PD-2017-06080