RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2020-00198
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E7, Intelligence Analyst, medically separated for “low back pain” and “bilateral lower leg pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.   

CI CONTENTION:  The conditions continue to worsen and negatively affect daily activities.  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 - 20060209	VARD - 20070109	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Degenerative Disc Disease	5237	20%	20061016	
Bilateral Lower Leg Pain due to Compartment Syndrome	5399-5311	0%	Status Post (S/P) Fasciotomy w/ Residual Right Lower Extremity Pain	5023	10%	20061016	
			S/P Fasciotomy w/ Residual Left Lower Extremity Pain	5023	10%	20061016	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in 1996 without a precipitating event.  During the 20 January 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported being in good health.  Physical examination showed lumbar spine tenderness and decreased range of motion (ROM) with flexion to 75 degrees (normal 90).  The 26 January 2006 MEB NARSUM examination noted CI complaints of “constant lower leg pain and lower back pain.”  Physical examination showed flexion to 60 degrees (only able to reach to knees) and combined ROM of 185 degrees (normal 240).  There was evidence of low back tenderness, but no paraspinal muscle spasm.
At the 16 October 2006 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported experiencing low back pain rated at 5-7/10, with radiation of pain down the right leg to the ankle.  Physical examination showed a normal gait and spinal curvature,   but no muscle spasm.  Forward flexion was to 60 degrees and combined ROM was 160 degrees, with painful motion during ROM testing in all planes of movement.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain), citing pain-limited flexion of 60 degrees without mechanical block.  The VA rated the back condition 20%, coded 5237, based on the C&P examination, citing thoracolumbar flexion greater than 30 degrees but not greater than 60 degrees.  Panel members agreed a 20% rating, but no higher, was justified for limitation of flexion as reported on the NARSUM and C&P examinations.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula. There was also no associated radiculopathy for a separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this was subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The panel therefore concluded that an additional disability rating was not justified on this basis.  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 5237.  

Bilateral Lower Leg Pain due to Compartment Syndrome.  According to the STR and MEB NARSUM, CI underwent fasciotomies of both lower extremities in June 2004, after experiencing bilateral leg pain since 1996.  During the MEB examination, the CI reported being in good health, and the examiner noted normal ROM and strength, minimal atrophy, and no tenderness. The MEB NARSUM examination documented CI complaints of “constant lower leg pain,” and physical findings revealed some numbness on the right side, but no tenderness and normal ankle ROM.  There was stiffness and tightness of the calf muscles during ankle extension, but painful motion was not recorded.  At the VA C&P examination, the CI reported tingling in the areas of the fasciotomy scars on both legs.  Physical examination showed decreased sensation and tenderness along the length of each scar (located between knee and ankle), but there was no muscle tenderness and no instability or functional limitation on standing or walking.  Bilateral lower extremity muscle strength was full, sensation intact to soft touch.  Although there was no objective evidence of pain during the examination, the CI offered verbal complaints of pain during bilateral ankle ROM testing, which was normal for both ankles and feet.  Repetition did not produce any additional pain, restriction on ROM, weakness, fatigability or incoordination.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB bundled the right and left lower extremity conditions under a single disability rating, analogously coded 5399-5311 (slight muscle disability of group 11), and rated 10%, citing “slight atrophic changes but no loss of strength.”  The VA rated the bilateral leg conditions 10% each, coded 5023 (myositis ossificans), based on the C&P examination, citing “painful or limited motion of a major joint or group of minor joints.” 

The panel first considered the evidence for separately rating each leg 10%, but the only findings at the MEB examinations included calf muscle tightness and stiffness during normal ankle ROM testing, with minimal atrophy and full muscle strength.   The C&P examiner noted decreased sensation and tenderness along each leg scar, but no muscle tenderness, functional loss, or foot/ankle ROM limitations.  Thus, the panel agreed a 0% rating, but no higher, was justified for the bilateral leg condition. There were no additional applicable codes that would result in a higher rating.  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 bilateral lower leg conditions.  

BOARD FINDINGS:  In the matter of the low back pain, the panel recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the bilateral lower leg pain and IAW VASRD §4.73, the panel recommends no change in the PEB adjudication.  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	
Chronic Mechanical Low Back Pain	5237	20%	
Bilateral Lower Leg Pain	5399-5311	0%	
COMBINED	20%	

The following documentary evidence was considered:

AR20210008023

Dear XXXXXXXXXXXXXXXX:

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.