RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX  	CASE:  PD-2020-00208
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050426

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E7, Unit Supply Specialist, medically separated for “low back pain (LBP)” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 20050408	VARD - 20051201	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP, Spondylosis and Degenerative Disc Disease	5299-5237	10%	Degenerative Disc Disease of the Lumbar Spine with Intermittent Right-Sided Sciatica	5243	40%	20050810	
Elevated Cholesterol	Not Unfitting	Increased Cholesterol	7199-7114	NSC	20050810	
Alopecia Areata	Not Unfitting	Alopecia Areata	7831	0%	20050810	
Pes Planus	Not Unfitting	Mild Bilateral Pes Planus (Claimed as Bilateral Pes Planus)	5276	10%	20050810	
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 low back condition began in April 1988 after basic training.  A 12 January 2005 medical board consult examination, 3 months prior to separation, noted complaints of LBP andphysical examination revealed tenderness over the lumbar region, right greater than left.  His neurologic examination was non-focal with no motor dysfunction.  There was normal balance andgait, and a normal neurological examination.  An MRI demonstrated mild degenerative joint disease changes in the lower three lumbar levels.  There was neither central stenosis nor spondylolisthesis, however, there was foraminal stenosis seen at L5-S1 on the left.  

During the 28 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI again reported LBP.  Physical examination was remarkable for tenderness to pressure around the entire lumbar area and decreased range of motion (ROM) due to pain.  

The 1 March 2005 MEB NARSUM examination several days later noted complaints of constant LBP that intermittently radiated down both lower extremities, and sometimes down to the right foot.  This was aggravated by any type of heavy lifting, repeated bending, impact activities, and standing or sitting for more than one hour, but he could walk at his own pace and distance without significant difficulty.  Physical examination revealed generalized tenderness from L1 down to the lumbosacral junction without palpable spasm or visible deformity.  Lumbar spine ROM showed flexion of 40 degrees (normal for isolated lumbar spine 60 degrees) and combined ROM of 170 degrees (normal for isolated lumbar spine 210) after repetition.  It was noted that the examiner specified lumbar spine motion, and not the thoracolumbar spine as required in the VASRD.  Painful motion was noted.  All measurements were made with a goniometer, except lumbar lateral rotation, which was an estimate.  Neurological examination revealed no abnormality.  

At the 10 August 2005 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported chronic pain in the lumbar area with flare-ups of sciatic pain radiating into the right leg following prolonged sitting, lasting for one to several days.  He denied weakness of the lower extremities and denied incapacitating episodes.  Physical examination showed a normal lumbar lordotic curve.  He was tender in the midline from L3 to S1.  There was no paraspinous spasm.  Thoracolumbar spine ROM showed flexion was limited to 60 degrees (normal 90) by pain. Straight leg raise testing reproduced LBP on the right but did not cause sciatica, and was negative for pain on the left.  Motor examination was 5/5 in all groups tested in the bilateral lower extremities.  Sensation was intact and deep tendon reflexes were 2+.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, analogously coded 5237 (lumbosacral strain), citing moderate decrease in ROM, limited by pain, with local tenderness noted, for which rated.  The VA rated the low back condition 40%, coded 5243 (intervertebral disc syndrome [IVDS]), based on a November 1995 VA C&P examination, citing flexion to 5 degrees.  It was noted that under new criteria the VA would have to assign a 20% evaluation based on the August 2005 examination that showed flexion of the thoracolumbar spine to 45 degrees.  

The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees), as reported on the August 2005 VA examination.  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is 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. 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 low back condition, coded 5237.  

Contended PEB Conditions:  Elevated Cholesterol, Alopecia Areata and Pes Planus.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the low back condition, the panel recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended elevated cholesterol, alopecia areata and pes planus conditions, the panel recommends no change from the PEB determinations as not unfitting.  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 Low Back Pain, Spondylosis and Degenerative Disc Disease	5237	20%	

The following documentary evidence was considered:  

Exhibit A.  DD Form 294, dated 20201211, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

	

AR20210011705, XXXXXXXXXX

Dear XXXXXXXXXX:

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.

Sincerely,