RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2022-00026
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090116

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Motor Vehicle Operator, medically separated for “chronic low back pain” with a disability rating of 10%.   

CI CONTENTION:  Review requested of low back and right shoulder pain as well as additional conditions (PTSD, eye injury) not identified by the Medical Evaluation Board (MEB) and/or 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 - 20081112	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	No VA Examination Proximate to Separation in Evidence	
Chronic Right Shoulder Pain	Not Unfitting		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Low Back Pain (LBP).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in November 2007 after slipping and falling on a snow-covered curb.  At a flight medicine visit on 14 April 2008, he reported LBP with occasional right lower extremity (RLE) numbness and tingling.  Physical findings showed reduced range of motion (ROM) with 50% of normal flexion and 75% of extension, and more pain during flexion than extension.  On 18 April 2008, spine X-rays were normal with no indication for surgery.  During a primary care visit on 28 April 2008, the CI complained of LBP with occasional muscle spasms but no LE weakness or numbness.  Physical examination revealed a normal gait and tenderness along the right and left paraspinal regions and in the sacral and sciatic notch areas.  Lumbosacral muscle spasms were present, and ROM was limited due to discomfort.  

At an orthopedic appointment on 18 June 2008, the CI complained of continued LBP, despite physical therapy (PT) and non-steroidal anti-inflammatory drugs, and reported a few episodes of diffuse RLE numbness while driving.  On examination, there was tenderness over the low back, worsened by twisting/bending, and some pain elicited with Faber (flexion, abduction, external rotation of the hip) testing.  Lumbar spine X-rays and an MRI were unremarkable.  The examiner’s assessment was lumbago/LBP without evidence of disc pathology or nerve root or spinal cord involvement.  There was no surgical indication.  

At a 2 July 2008 PT visit, the CI reported LBP with LE numbness and occasional paresthesia to the mid calves, especially while driving or sitting.  Physical findings recorded poor posture but a normal gait with good heel and toe walk.  Back ROM showed normal flexion with painful motion, extension decreased by 40%, and normal side-bending and rotation on both sides.  

During the 17 October 2008 MEB NARSUM examination, 3 months prior to separation, the CI complained of continued LBP with tingling in the anterior RLE after prolonged sitting, and numbness if he did not stand up and walk around.  He rated his current LBP at 5-6/10 in intensity, which had improved from 8-10/10.  The examiner noted that the CI “slowly rose from his chair and walked back to the exam room with a noticeable limp favoring of the right leg.”  On examination, there was no abnormal spinal curvature or muscle tension.  There was tenderness but only to percussion of the lower mid-line spine.  Spinal ROM testing after three repetitions (with a goniometer) revealed flexion to 80 degrees (normal 90), extension to 25 degrees (normal 30), and bilateral rotation and flexion to 30 degrees (normal).  There was no VA Compensation and Pension (C&P) examination in evidence near separation.  

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 flexion of 75 degrees and consideration of functional loss due to painful motion.  Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB NARSUM examination.  While muscle spasm was recorded in an earlier examination, it was not severe enough to result in an abnormal gait or spinal contour.  The MEB NARSUM examiner noted an abnormal gait, however, there was no muscle spasm or guarding, thus the panel agreed the evidence did not support the next higher 20% rating 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 low back condition.  

Contended PEB Condition: Right Shoulder Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended shoulder condition was not unfitting.  Since 2003, the CI had a U2 profile for the right shoulder, which requires some physical limitations but is not disqualifying in all cases for continued military service.  This condition was not 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 shoulder condition, 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.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20210921, w/atchs
Exhibit B.  Service Treatment Record

AR20230002066, XXXXXXXXXX

XXXXXXXXXX

Dear XXXXXXXXXX:

	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.