RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2021-00059
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050413

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E3, Wheel Vehicle Repairer, medically separated for “chronic back pain” with a disability rating of 10%.  

CI CONTENTION:  The back condition continues to worsen and affects the ability to perform duties.  Review also requested 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 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 - 20050325	VARD - 20050222	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5243	10%	Post Laminectomy Syndrome	5243	10%	20050222	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent a lumbar laminectomy in July 2004, but continued to have back pain.  A repeat MRI showed recurrent disc herniation at L5-S1, but electrodiagnostic studies were normal.

During the 30 December 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported recurrent back pain that interfered with sleeping.  Physical examination showed tenderness, and passive range of motion (ROM) testing revealed 40 degrees of flexion (normal 90) and 165 degrees of combined ROM (normal 240).  The 12 January 2005 MEB NARSUM examination, 3 months prior to separation, showed findings identical to the MEB examination, but did not include the comment “passive ROM.” 

At the 22 February 2005 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported constant back pain rated at 8/10, which traveled into the right lower extremity (RLE) and affected the ability to bend, twist, and lift.  He also reported a 90-day incapacitating episode.  Physical examination showed an abnormal gait due to RLE pain and “distal weakness.”  There was no spasm, tenderness, or ankylosis noted.  The ROM study showed 75 degrees of flexion and 195 degrees of combined ROM, with pain in all planes of movement.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5243 (intervertebral disc syndrome), citing “ROM limited by pain, with localized tenderness.”  The VA also rated the back condition 10%, coded 5243, based on the C&P examination, citing limitation of forward flexion.  Although the ROM values reported on the NARSUM and MEB examinations were significantly worse than those reported on the VA examination, the MEB examination documented “passive” ROM and the NARSUM recorded identical ROM without specifying active or passive ROM values.  Panel members agreed that the VA ROM, which was most proximate to separation, appeared more reflective of the anticipated severity based on the clinical pathology.  Although the CI reported a 90-day incapacitating episode during the previous year, the STR showed only 7 days of prescribed quarters.  Therefore, a higher rating was not obtainable for incapacitating episodes.  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.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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.    

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20210422, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20210017117, XXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXX:

	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.

Sincerely,