RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 
NAME:  XXXXXXXXXXXXXXXXX                                                     BRANCH OF SERVICE:  ARMY  
CASE NUMBER:  PD1101074                                                             SEPARATION DATE:  20030228 
BOARD DATE:  20121010   
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered  individual  (CI)  was  an  active  duty  CPL/E-4  (13M/MLRS  Crewmember),  medically 
separated for chronic low back pain (LBP).  The CI initially injured his back when he fell in a 
shower at his home, but later he reinjured the back in a motor vehicle accident.  Despite L3 
back  fusion  surgery,  wearing  an  external  orthotic  for  3  months,  medications,  TENS  unit  and 
physical  therapy  (PT)  the  CI  failed  to  meet  the  physical  requirements  of  his  Military 
Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued an L3 profile 
and referred for a Medical Evaluation Board (MEB).  The MEB forwarded lumbar degenerative 
disc disease (DDD) with LBP to the Informal Physical Evaluation Board (IPEB) on DA Form 3947 
as medically unfitting.  The MEB forwarded no other conditions for PEB adjudication.  The PEB 
adjudicated the chronic LBP status post (s/p) L3-S1 fusion condition as unfitting, rated 10% with 
specified application of Department of Defense Instruction (DoDI) 1332.39 and AR 635-40.  The 
CI appealed to the Formal PEB (FPEB) and the U. S. Army Physical Disability Agency (USAPDA) 
reviewed  the  entire  case  file  and  reaffirmed  the  IPEB  and  FPEB’s  findings.    The  CI  was  then 
medically separated with a 10% disability rating.   
 
 
CI CONTENTION:  The CI elaborated no specific contention in his application.   
 
 
SCOPE OF REVIEW:  The Board wishes to clarify that the scope of its review as defined in DoDI 
6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined 
by the PEB to be specifically unfitting for continued military service; or, when requested by the 
CI, those condition(s) “identified but not determined to be unfitting by the PEB.”  The unfitting 
chronic LBP S/P L3-S1 fusion condition meets the criteria prescribed in DoDI 6040.44 for Board 
purview, and is accordingly addressed below.  Any conditions or contention not requested in 
this application, or otherwise outside the Board’s defined scope of review, remain eligible for 
future consideration by the Army Board for Correction of Medical Records.   
 
 
RATING COMPARISON:   
 

VA (1 Mos. Post-Separation) – All Effective Date 20030301 

*Per VARD dated 20070302 Lumbar Spine condition increased to 40% effective 20050126, Bilateral Plantar Fasciitis increased to 
10% effective 20060928 (combined 60%) 
 
 
ANALYSIS SUMMARY:   

Service FPEB – Dated 20021219 
Condition 

Code 

Chronic LBP, Status Post 

L3-S1 Fusion 
↓No Additional MEB/PEB Entries↓ 

5299-5295 

Rating 
10% 

Combined:  10% 

Condition 

Residuals, Lumbar Spine 
Postoperative with DDD 
Environmental Allergies Disease 

Code 

5293-5295 

6522 

Rating 
20%* 
10% 

0% X 5 / Not Service-Connected x 1 

Combined:  30%* 

Exam 

20030310 
20030310 

 

 
Chronic LBP, Status Post L3-S1 Fusion Condition.  The 2003 Veterans’ Administration Schedule 
for Rating Disabilities (VASRD) coding and rating standards for the spine, which were in effect at 
the  time  of  separation,  had  been  modified  on  23  September  2002  to  add  incapacitating 
episodes (5293 Intervertebral disc syndrome), and were changed to the current §4.71a rating 
standards  on  26  September  2003.    The  2003  standards  for  rating  based  on  range-of-motion 
(ROM) impairment were subject to the rater’s opinion regarding degree of severity, whereas 
the current standards specify rating thresholds in degrees of ROM impairment.  For the reader’s 
convenience, the 2003 rating codes under discussion in this case are excerpted below.   
 

5292 Spine, limitation of motion of, lumbar: 
Severe........................................................  
Moderate......................................................  
Slight........................................................   
5293 Intervertebral disc syndrome: (extracted) 
Evaluate  intervertebral  disc  syndrome  (preoperatively  or  postoperatively)  either  on  the  total  duration  of 
incapacitating episodes over the past 12 months or by combining under Sec. 4.25 separate evaluations of its 
chronic  orthopedic  and  neurologic  manifestations  along  with  evaluations  for  all  other  disabilities,  whichever 
method results in the higher evaluation. 

40 
20 
10 

Note (1): For purposes of evaluations under 5293, an incapacitating episode  is a period of acute signs and 
symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment 
by a physician. ``Chronic orthopedic and neurologic manifestations'' means orthopedic and neurologic signs 
and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. 

5294 Sacro-iliac injury and weakness: 
5295 Lumbosacral strain: 
Severe; with listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward 
bending in standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of 
joint space, or some of the above with abnormal mobility on forced motion................................ 
With muscle spasm on extreme forward bending, loss of lateral (side bending) 
spine motion, unilateral, in standing position...............  
With characteristic pain on motion............................  
With slight subjective symptoms only..........................  

40 

 
 
 

20 
10 
0 

 
There  were  three  back  evaluations  in  evidence  with  documentation  of  additional  ratable 
criteria, which the Board weighed in arriving at its rating recommendation; as summarized in 
the chart below.   
                              

MEB ~ 7 Mo. Pre-Sep 

DDF 2808 ~5 Mo. Pre-Sep 

VA C&P ~1 Mo. Post-Sep 

Thoracolumbar ROM 
Flexion (90⁰ Normal) 

Ext (0-30) 

R Lat Flex (0-30) 
L Lat Flex 0-30) 
R Rotation (0-30) 
L Rotation (0-30) 
Combined (240⁰) 

Comment:   

Fusion surgery ~11 

Mo. Pre-Sep 

§4.71a Rating 

80⁰* 
30⁰* 

NO ROM’s 

minimal myofascial TTP; 
“radiating bilateral sciatic 
pain with ambulation and 
bilateral paresthesias”; 
motor/sensory intact; 
normal gait; reflexes nml 

10% 

- 

- 

*With tenderness; TTP; 
pain to knee joint; muscle 
strength 5/5 with 4/5 Rt 

leg flexion 

10% 

50⁰ (30⁰-50⁰)* 
20⁰ (10⁰-20⁰)* 
30⁰ (20⁰-30⁰)* 
30⁰ (20⁰-30⁰)* 

No ROM’s 

N/A 

*(Painful motion); Joints weaker 
throughout ROM when resistance 

was applied; fatigability with 
repetitive use; TTP; no muscle 
atrophy; nml gait; DTR’s 2+; 

sensation intact 

20 % 

* TTP = Tenderness to palpation 
 
The  CI’s  back  pain  was  well  documented  in  the  service  treatment  record  (STR).    A  magnetic 
resonance imaging (MRI) performed in February 2000 demonstrated a moderate disc extrusion 

at  L5-S1  with  spinal  stenosis  and  nerve  root  impingements  on  the  right  at  L4-5.    The  CI 
underwent  orthopedic  evaluations  and  extensive  PT  with  poor  results.    He  underwent  a 
posterior lumbar interbody fusion (PLIF) in March 2002, 11 months prior to separation.  The CI’s 
back  pain  post-operatively  showed  minimal  improvement.    The  MEB  examination  performed 
7 months prior to separation noted that PT had caused a 50% improvement with  symptoms; 
however, there were still complaints of occasional sciatic pain, paresthesias with ambulation, 
and  constant  dull  LBP  with  intermittent  throbbing  sharp  pain.    The  exams  are  summarized 
above with a noted disparity in right leg strength between the MEB and DD Form 2808 exams.  
Both indicated normal straight leg raise.  Records did not demonstrate any periods of physician 
prescribed bed rest (incapacitation).   
 
The  VA  Compensation  &  Pension  (C&P)  examination  performed  one  month  after  separation 
indicated complaints of weakness, stiffness, fatigability, lack of endurance, pain on a daily basis 
requiring  use  of  a  TENS  unit  and  narcotic  medication  on  an  intermittent  basis.    The  CI’s 
functional limitations were an inability to participate in recreational activities and an inability to 
do  extended  driving.    Although  the  CI  complained  of  an  intermittent  right  leg  radiculopathy 
(pain  and  paresthesias),  an  electrophysiological  study  (NCV/EMG)  “did  not  reveal  significant 
abnormal electrical signs…there is no electromyography evidence of radiculopathy.”  The exam 
summarized above indicated normal motor strength and normal gait.   
 
The Board directs attention to its rating recommendation based on the above evidence.  The 
Board noted that the CI’s overall condition and described history were congruent between all 
exams.  The Board considered the PEB’s rating under the 5295 code.  All exams documented 
characteristic pain on motion.  The VA exam had findings that demonstrated deterioration of 
the ROM in flexion and extension, especially on repetition with increased fatigue and weakness.  
There was little indication of repetitive motion assessment in the STR.  Continued use of TENS, 
episodic narcotic use and radiating pain were well documented.  The VA exam was closest to 
separation  and  adjudged  to  have  the  higher  probative  value.    After  due  deliberation, 
considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.7 (higher 
of two evaluations), the Board recommends a disability rating of 20% for the chronic LBP, status 
post (s/p) L3-S1 fusion condition.   
 
 
BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or 
guidelines relied upon by the PEB will not be considered by the Board to the extent they were 
inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB 
reliance on DoDI 1332.39 and AR 635-40 for rating the back condition was operant in this case 
and  the  condition  was  adjudicated  independently  of  that  instruction  by  the  Board.    In  the 
matter  of the  chronic  LBP  s/p  L3-S1  fusion  condition, the  Board  unanimously  recommends a 
disability rating of 20%, coded 5293-5295 IAW VASRD §4.71a.  There were no other conditions 
within the Board’s scope of review for consideration.   
 
 
RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as 
follows, effective as of the date of his prior medical separation:   
 

VASRD CODE  RATING 
5293-5295 
COMBINED 

20% 
20% 

Chronic LBP Status Post(s/p) L3-S1 Fusion 

UNFITTING CONDITION 

 

 
 
The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20110909, w/atchs 
Exhibit B.  Service Treatment Record 
Exhibit C.  Department of Veterans’ Affairs Treatment Record 
 
 
 
 
 
 
 
 

 

           XXXXXXXXXXXXXXXXXXXXX 
           President 
           Physical Disability Board of Review 

SFMR-RB 
 

 

 
 

 

 

 
 

 

 
 

MEMORANDUM FOR Commander, US Army Physical Disability Agency  
(TAPD-ZB /  ), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557 
 
 
SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation  
for XXXXXXXXXXXXXXXXXXX, AR20120019252 (PD201101074) 
 
 
1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review 
(DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  
Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s 
recommendation to modify the individual’s disability rating to 20% without recharacterization 
of the individual’s separation.  This decision is final.   
 
2.  I direct that all the Department of the Army records of the individual concerned be corrected 
accordingly no later than 120 days from the date of this memorandum.    
 
3.  I request that a copy of the corrections and any related correspondence be provided to the 
individual concerned, counsel (if any), any Members of Congress who have shown interest, and 
to the Army Review Boards Agency with a copy of this memorandum without enclosures. 
 
 BY ORDER OF THE SECRETARY OF THE ARMY: 
 
 
 
 
Encl 
 
 
 
CF:  
(  ) DoD PDBR 
(  ) DVA 
 

     XXXXXXXXXXXXXXXXXX 
     Deputy Assistant Secretary 
         (Army Review Boards)