RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXX	CASE:  PD-2020-00015
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Fire Support Specialist, medically separated for “low back pain” with a disability rating of 0%.  

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 - 20040927	VARD - 20050308	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5237	0%	Herniated Nucleus Pulposus, L5-S1	5243	20%	20050203	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back pain began in December 2002 while road marching during basic training.  Radiographic studies showed degenerative disc disease with a mild herniated disc at L5-S1 and surgery was not recommended.  The 16 July 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of daily, non-radicular low back pain aggravated by prolonged walking, standing, running, bending and sit-ups.  Physical examination showed a normal gait and straight back.  Range of motion testing, after three repetitions, revealed flexion to 60 degrees and combined ROM of 150 degrees, with pain in all planes of motion.  During the 5 August 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported back pain with left leg numbness and tingling, and the examiner noted “pain with forward flexion at 70 degrees.”  

At the 3 February 2005 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported intermittent sciatica 4-5 times a week and daily back pain, rated at 7/10, but that he could “comfortably lift 25 pounds and sit for 30 to 35 minutes.”  He denied having back spasms.  Physical examination showed a normal gait and that he could rise from a chair with no difficulty.  Sensation, reflexes and motor strength were normal.  “Lumbar function [was] limited to 60 degrees” and combined ROM was 160 degrees, after repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, analogously coded 5299-5237 (lumbosacral strain), citing flexion to 75 degrees and extension to 18 degrees, both limited by pain.  The VA rated the back condition 20%, coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P examination, citing thoracolumbar flexion greater than 30 degrees but not greater than 60 degrees.  Panel members agreed that a 20% rating, but no higher, was justified for limitation of flexion, as reported on the NARSUM and VA examinations.  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 recommends a disability rating of 20% for the back condition, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 20%, coded 5299-5237 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain	5299-5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20200114, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20200006682, 

Dear XXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application