RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX		CASE: PD-2018-00426 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20060321

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

CI CONTENTION: “Still having trouble with my back. I claimed injuries that were listed as non- service related. Still have trouble with my hearing. Have trouble with my arms still going to sleep.” The CI requested review of additional conditions 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 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 – 20060126	VARD – 20061130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-
5237	10%	Mild Disc Desiccation at L4-L5 with Normal Disc Height	5239	10%	STR	
Right Carpal Tunnel Syndrome	Not Unfitting	Right Carpal Tunnel Syndrome	8699-8715	0%	STR	
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’s back condition began in April 2002 after falling into a hole during a night land navigation course. The pain temporarily resolved, but was aggravated in March 2004 when the CI was involved in a motor vehicle accident. An MRI on 18 May 2005 showed mild desiccation with preservation of disc height at L4-L5 with mild left foraminal disc bulge contacting the exiting L4 nerve root without compression.

The 14 July 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, revealed paraspinal lumbosacral tenderness with limitation flexion, extension and lateral rotation. Gait was normal. Thoracolumbar range of motion (ROM) measurements performed by physical therapy (PT) on 5 December 2005, 4 months prior to separation, showed

flexion of 70 degrees (normal 90) and combined ROM of 200 degrees (normal 240) after repetition, with associated painful motion. At the 12 January 2006 MEB NARSUM examination, 2 months prior to separation, the CI reported right lower back pain, described as dull to crushing pain without radiation. Physical examination revealed normal tandem, toe and heel walking. There was very mild tenderness of the paravertebral lumbar region. ROM “appeared to be normal through flexion and extension; however he did note flexion as more painful than extension.” There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing thoracolumbar ROM of 250 degrees and tenderness. The VA also rated the back condition 10%, coded 5239 (spondylolisthesis or segmental instability), based on the STR, citing forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, combined ROM greater than 120 degrees, but not greater than 235 degrees. The panel agreed that a 10% rating, but no higher, was justified for the limitation of flexion and combined ROM as reported on the MEB PT ROM examination and as cited by the VA rating. 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 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.

Contended PEB Condition: Right Carpal Tunnel Syndrome. The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. The contended condition was not profiled or implicated in the commander’s statement and did not fail retention standards. There was no performance-based evidence from the record that the condition 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 the contended condition so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended right carpal tunnel syndrome, the panel recommends no change from the PEB determination 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.

2	PD-2018-00426

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

AR20190015530

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.

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