RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200649 SEPARATION DATE: 20020417 

BOARD DATE: 20130418 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (62B/Heavy Equipment Repair) medically 
separated for low back pain (LBP). The CI injured his back in 1992. He was treated, but did not 
improve adequately to fully perform his military duties or meet physical fitness standards. He 
was issued a permanent P2/L3 profile and underwent a Medical Evaluation Board (MEB). The 
MEB forwarded lumbar degenerative disk disease (DDD) and postsurgical pain from left iliac 
crest site to the Physical Evaluation Board (PEB) IAW AR 40-501, and no other conditions were 
submitted by the MEB. The Physical Evaluation Board (PEB) combined the two MEB conditions 
and found the CI unfit for military service due to back pain and moderate limitation of lumbar 
range-of-motion (ROM). The unfitting condition was rated 20%, with likely application of the 
Veteran’s Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals, and 
was medically separated with a 20% disability. 

 

 

CI’s CONTENTION: The CI states: “I had back surgery which I had my L4-L5 cage fusion was 
done on my back. It caused me to give up on my career. I had 14 years in. My condition 
caused me to lose my way of life. I can’t move without my legs going out and I am in a wheel 
chair since I have gotten out of the military. I am now wearing Depends because the back 
surgery has made me lose my bladder control. I have to take Viagra. I have to take pain 
medicine all the time. I cannot [expletive deleted] like I did when I joined the military. I was 
going to stay in and retire until I hurt my back. But since then it has been a living hell.” 

 

 

SCOPE OF REVIEW: The Board’s scope of 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 back 
condition (back pain and moderate limitation of range of motion of the lumbar spine) meets 
the criteria prescribed in DoDI 6040.44, and is accordingly addressed below. No other condition 
is within the Board’s purview. Any condition outside the Board’s defined scope of review may 
be eligible for future consideration by the Army Board for Correction of Military Records. 

 

 

RATING COMPARISON: 

 

Army PEB – dated 20011211 

VA (2 & 3 mos. Pre-Separation) – All Effective 20020418 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Back Pain and Limited 
Lumbar Range of Motion 

5292 

20% 

Post-Operative Residuals, 
Lumbosacral Spine 

5293 

60% 

20020128 

.No Additional MEB/PEB Entries. 

Cervical Strain 

5290 

30% 

20020128 

Neurogenic Bladder 

7542 

20% 

20020128 

TMJ Syndrome w/Malocclusion 

9905 

10% 

20020222 

Bilateral Tinnitus 

6260 

10% 

20020130 

0% X 3 / Not Service-Connected x 1 

20020128 

Combined: 20% 

Combined: 80% 



 


ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed by the CI regarding 
the impairment with which his conditions continue to burden him, and the significant impact 
they have had on his quality of life. It is noted for the record that the Board is subject to the 
same laws for Service disability entitlements as those under which the Disability Evaluation 
System (DES) operates. The DES has neither the role nor the authority to compensate members 
for future severity or potential complications of conditions. That role and authority is granted 
to the Department of Veterans Affairs (DVA). The Board evaluates DVA evidence in arriving at 
its recommendations, but its authority resides in evaluating the fairness of DES fitness and 
rating determinations at the time of separation. While the DES considers all of the CI's medical 
conditions, compensation can only be offered for those conditions that cut short a member’s 
career, and then only to the degree of severity present at the time of separation. The DVA, 
however, is empowered to compensate for service-connected conditions and to periodically re-
evaluate conditions for the purpose of adjusting the Veteran’s disability rating should the 
degree of impairment change over time. 

 

Low Back Pain (LBP). The CI developed LBP in 1992. Initially he was treated conservatively with 
physical therapy (PT) and medication, but his LBP persisted. In August 1998, he underwent 
back surgery, with spinal fusion of L4-L5 using bone cages and pedicle screws. Post-operatively 
he continued to have LBP. On 17 July 1999, the CI was seen by neurosurgery. The neurological 
examination was essentially normal. Station and gait were normal, and the CI was able to heel 
and toe walk. The examiner stated, “In summation, the patient lacks objective findings on his 
physical examination, but clearly demonstrates subjective pain.” In March 2001, the CI 
underwent a Urological work-up due to his urinary symptoms and erectile dysfunction (ED). A 
voiding study showed sensation was intact, and bladder compliance was normal, with no 
evidence of detrusor sphincter dysinertia (DSD). The CI was referred to the Pain Management 
Clinic at Walter Reed Army Medical Center. Several different treatment options were tried, but 
his LBP continued. Because of persistent problems with LBP, an MEB was initiated. His MEB 
clinical evaluation was on 10 October 2001. Examination revealed some tenderness to 
palpation (TTP) over the lower lumbar spine, but there were no signs of spinal deformity. 
Reflexes and muscle strength were normal. Sensation was decreased to pinprick and light 
touch over the dorsolateral aspect of the right foot. Straight leg raise (SLR) was negative. 
Electromyography (EMG) on 24 October 2001 showed no evidence of lumbar radiculopathy. 

 

On 28 January 2002, 3 months prior to separation, the CI had a VA Compensation and Pension 
(C&P) exam. The CI reported severe LBP at rest. Exam of the lower back revealed painful 
motion and tenderness to palpation (TTP). There was no tenderness of the posterior iliac crest 
bilaterally. SLR was positive for both right and left legs. Pain increased with dorsiflexion of 
each foot. Leg length was equal bilaterally. There was decreased sensation to light touch at 
both feet. Posture was limited due to pain in the lower back. Gait was abnormal. He was using 
a cane for support while walking. He could not toe or heel walk, secondary to pain at the lower 
back. Pulses were 2+ and equal in the lower extremities. Motor function was within normal 
limits for both lower extremities. He had severe pain in the lower back with muscle strength 
testing. Deep tendon reflexes were symmetric bilaterally. There was markedly reduced ROM 
at the lumbar spine. The two ROM evaluations which the Board weighed in arriving at its rating 
recommendation are summarized in the chart below. 

 


Thoracolumbar ROM 

MEB ~6 Mo. Pre-Sep 

(20011010) 

VA C&P ~3 Mo. Pre-Sep 

(20020128) 

Flexion (90° Normal) 

30° 

10° 

Ext (0-30) 

10° 

5° 

R Lat Flex (0-30) 

10° 

20° 

L Lat Flex 0-30) 

10° 

20° 

R Rotation (0-30) 

 

15° 

L Rotation (0-30) 

 

15° 

Combined (240°) 

 

85° 

Comment 

+ Tenderness; spasm; 
abnormal gait 

+ Tenderness; painful motion 
in all directions; gait 
abnormal; walks w/cane 



 

 

The Board carefully reviewed all of the evidentiary information available, and directs attention 
to its rating recommendation based on the above evidence. The Army PEB and the VA used 
different coding and rating options for the LBP condition. The PEB coded it 5292 and assigned a 
rating of 20% (moderate limitation of lumbar motion). The VA used code 5293 (Intervertebral 
disc syndrome) and rated it 60%. The VASRD coding and rating standards for the spine, which 
were in effect at the time of the CI’s separation, were modified in September 2002, and then 
were changed again in September 2003. The older standards were based on the rater’s opinion 
regarding degree of severity, whereas current standards specify certain rating thresholds, with 
measured degrees of ROM impairment. IAW DoDI 6040.44, the Board must use the VASRD 
coding and rating standards which were in effect at the time of the CI’s separation from service. 

 

The Board noted the disparity between the two ROM exams. Forward flexion was only 10 
degrees at his January 2002 C&P exam. However, there were certain inconsistencies in that 
C&P exam, which caused the Board to question its validity and probative value. A 10 degree 
limitation of forward flexion would almost preclude some activities of daily living (ADLs) such as 
sitting in a chair, or riding in a car. The record does not indicate that the CI was unable to sit in 
a chair or ride in a car. In fact, the record states that he was able to drive for about an hour. 
Furthermore, a sitting blood pressure was taken, proving that he was able to sit in a seated 
position. The Board determined that these inconsistencies caused some diminution in the 
validity and probative value of the January 2002 C&P exam. 

 

Based on the evidence in the service treatment record (STR), the Board determined that IAW 
VASRD §4.71a, the diagnostic code which most closely aligns with limited lumbar motion is 
5292 (Spine, limitation of motion of, lumbar). Under code 5292, the rating levels are: 10% for 
slight, 20% for moderate, and 40% for severe. Following a thorough review of the record, the 
Board unanimously agreed that the CI’s chronic back pain condition was best described as 
“moderate.” There was insufficient evidence to support classifying the condition as “severe.” 
After due deliberation, the Board determined that a separation disability rating of 20% was 
warranted, due to the moderate lumbar motion impairment. The Board tried to find a path to a 
rating higher than 20%, using other codes which could be applied to the chronic back pain 
condition. The other VASRD codes that were considered did not result in a rating higher than 
20%, since the STR did not show sufficient evidence of a disabling lumbar spine abnormality 
which would justify a rating higher than 20%. Considering all of the evidence and mindful of 
VASRD §4.3 (resolution of reasonable doubt), the Board concluded that there was insufficient 
cause to recommend a change in the PEB adjudication for the back pain 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. In the matter of the back 
pain condition, the Board unanimously recommends no change in the PEB adjudication, IAW 


VASRD §4.71a. There were no other conditions within the Board’s scope of review for 
consideration. 

 

 

RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of 
the CI’s disability and separation determination, as follows: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Back pain, and moderate limitation of lumbar range of motion 

5292 

20% 

COMBINED 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120503, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Director of Operations 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
xxxxxxxxxxxxxxxxxxxxxxxx, AR20130009545 (PD201200649) 

 

 

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 and hereby deny the individual’s application. 

This decision is final. The individual concerned, counsel (if any), and any Members of Congress 
who have shown interest in this application have been notified of this decision by mail. 

 

 BY ORDER OF THE SECRETARY OF THE ARMY: 

 

 

 

 

Encl xxxxxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)