RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200686 SEPARATION DATE: 20031031 

BOARD DATE: 20121221 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty PFC/E-3 (13M/Multiple Launch Rocket System 
Operator), medically separated for chronic low back pain (LBP) due to degenerative disc disease 
(DDD) with Bertolotti’s Syndrome (partial sacralization L5-S1). The CI first injured his back in a 
motor vehicle accident (MVA) in 2001 which worsened after being kicked by a horse in May 
2002. He did not respond adequately to non-operative therapy to include multiple facet 
epidural and pseudoarthrosis injections and physical therapy to meet the physical requirements 
of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued 
a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded 
the two conditions of DDD of multi level discs in the lumbar spine and Bertolotti's syndrome for 
Physical Evaluation Board (PEB) adjudication. The PEB combined DDD of multi-level discs in the 
lumbar spine condition and Bertolotti’s Syndrome condition as “Chronic Low Back Pain due to 
Degenerative Disc Disease with Bertolotti’s Syndrome” and adjudicated it as unfitting, rated 
10% with application of the Department of Defense Instruction (DoDI) 1332.39. There were no 
other fitting or unfitting conditions identified. The CI made no appeals, and was medically 
separated with a 10% disability rating. 

 

 

CI CONTENTION: “My initial rating for cervical strain & DDD with Bertolotti’s Syndrome should 
be reviewed because it was only partially addressed in the medical board. Other issues 
occurred at the same time of the injury that are documented in my service medical record, i.e. 
hips, legs, that have gone unnoticed. I was noted to have a hip deficiency of 11mm which 
required orthodic heel lifts to address the hip and back pain. I feel that my rating was given 
based on that I had a disability & not how severe the disability is. In regards to my back there 
were more problems documented in my spine/neck than just my L4-L5 area alone. My service 
records and VA medical records will reflect this. Also I have finally been able to get the VA to 
address that my injuries are secondary to the same injury. These records to include disability 
for my hips and mood (anxiety/PTSD) are included” 

 

 

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 ratings 
for unfitting conditions will be reviewed in all cases. The rated condition chronic LBP due to 
DDD with Bertolotti’s Syndrome as requested for consideration is the only condition that meets 
the criteria prescribed in DoDI 6040.44 for Board purview; and, is addressed below. The 
remaining conditions rated by the VA at separation and listed on the DD Form 294 are not 
within the Board’s purview. 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 Military Records. 

 

 

 

 


RATING COMPARISON: 

 

Service PEB – Dated 20030924 

VA (3 Mos. Post-Separation) – All Effective Date 20031101 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Low Back Pain 
due to DDD and 
Bertotolli’s Syndrome 

5299-5295 

10% 

Degenerative Disc Disease with 
Bertolotti’s Syndrome and Low 
Back Strain 

5243-5237 

10% 

20040124 

.No Additional MEB/PEB Entries. 

Cervical Strain 

5237 

10% 

20040124 

Combined: 10% 

Combined: 20% 



Note: CI received a VARD dated 20041020 which was 11 months after separation but received the same VA Ratings for his 
conditions with nothing added. 

 

 

ANALYSIS SUMMARY: The PEB combined DDD of multi-level discs in the lumbar spine and 
Bertolotti's syndrome as the single unfitting and solely rated condition, coded analogously to 
5299-5295. Bertolotti's syndrome is a lumbar spine condition and was appropriately combined 
for rating with the lumbar spine DDD. The PEB rating was under the old spine rules prior to the 
26 September 2003 effective date of the current Veterans Administration Schedule for Rating 
Decisions (VASRD) spine criteria. Since the CI’s 31 October 2003 date of separation was after 
that effective date, the PDBR rating recommendation is based on the newer VASRD spine 
criteria which were effective on the date of separation. The Board considered the 
commander’s statement in detail. 

 

Chronic Low Back Pain due to Degenerative Disc Disease and Bertotolli’s Syndrome Condition. 
The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in 
arriving at its rating recommendation, with documentation of additional ratable criteria, are 
summarized in the chart below. 

 

Thoracolumbar ROM 

MEB ~3 Mo. Pre-Sep 

(20030808) 

VA C&P ~3 Mo. Post-Sep 

(20040124) 

Flexion (90° Normal) 

20° 

80° 

Ext (0-30) 

10° 

20° 

R Lat Flex (0-30) 

10° 

20° 

L Lat Flex 0-30) 

10° 

30° 

R Rotation (0-30) 

- 

30° 

L Rotation (0-30) 

- 

(30°) 45° 

Combined (240°) 

- 

210° 

Comment 

Negative SLR; normal 
strength, reflexes, and 
sensory exam (See text) 

Gait normal; + mild tenderness; no 
spasm; ROM not painful; normal 
neurologic exam 

§4.71a Rating 

40% (PEB 10%) 

10% 



 

At the MEB exam, the CI reported “low back pain and stiffness without leg symptoms.” The 
MEB physical exam noted normal muscle strength of the lower extremities, no loss of reflexes, 
and normal sensory perception. The exam is summarized above with the charted ROMs 
extracted from the quoted: “Range of motion, he has 10 degrees of extension, bending left and 
right of the lumbar spine and can flex 20 degrees.” No spasm, abnormal spine contour or gait 
was addressed or documented. The examiner stated “This would be considered mild 
intervertebral disc syndrome”. Imaging documented partial sacralization L5-S1 (Bertotolli’s 
Syndrome), lumbar degenerative joint disease (DJD), with central asymmetrical disk bulge or 
broad-based disk protrusion, with mild impingement on the thecal sac, but no central canal 
stenosis. Treatment notes from physical medicine, 5 months prior to separation indicated 
forward flexion to 60 degrees with pain; subsequent pain clinic evaluation 2 days later 
documented pain-limited extension to 15 degrees with forward flexion to 90 degrees. 

 


At the VA Compensation and Pension (C&P) exam 3 months after separation, the CI reported 
LBP, 6/10 scale, worse with bending, sitting or lifting heavy weight. The CI reported that flare 
ups would cause temporary decrease in ROM due to pain and stiffness. The CI denied bowel or 
bladder problems and was able to walk 1-1/2 to 2 miles. The examiner stated “his day-to-day 
activities are not precluded by the spine condition. He works as a full-time student.“ The C&P 
exam is summarized above. The remote from separation, VA exam in November 2006, 
documented slight pain-limited ROM and the VA continued their 10% rating based on that 
exam. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB coded 5299-5295, lumbosacral strain at 10% for characteristic pain on motion. The PEB 
was one day after the effective date of the new spine rules and use of code 5295 and the PEB 
disability description indicates application of the older spine rating criteria with application of 
DoD and service specific rules. The VA 10% rating was coded 5243-5237 using the newer 
VASRD spine criteria and coding. No records documented periods of incapacitation or fixed 
peripheral neuropathy. The service exam and the VA exam indicated major differences on the 
ROM measurement. It is obvious that there is a clear disparity between these examinations, 
with very significant implications regarding the Board's rating recommendation. The Board 
thus carefully deliberated its probative value assignment to these conflicting evaluations, and 
carefully reviewed the service file for corroborating evidence in the 12-month period prior to 
separation. The exams were about the same time prior to and after separation. The exam did 
not address gait or any other functional criteria that would align with the significant ROM 
limitations noted, and the exam was otherwise considered “mild.” The VA exam was more 
comprehensive. The Board considered the tenants of VASRD §4.7 (higher of two evaluations), 
but determined that the CI’s disability picture best fit the disability level noted at the C&P exam 
and that this exam held the higher probative value with respect to the CI’s condition at 
discharge. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 
(reasonable doubt), the Board concluded that there was insufficient cause to recommend a 
change in the PEB’s 10% adjudication for the chronic LBP due to DDD with Bertolotti’s 
Syndrome condition; However, the disability code should be administratively corrected to 
5243-5237, as code 5295 was no longer in effect at the date of separation. 

 

 

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, AR 635-40, Appendix B·39, and the older VASRD were operant in this 
case and the condition was adjudicated independently of those instructions by the Board, and 
with use of the VASRD effective at the time of separation. In the matter of the chronic LBP due 
to DDD with Bertolotti’s Syndrome condition and IAW VASRD §4.71a, the Board unanimously 
recommends no change in the PEB’s 10% rating adjudication, but a modification to coding to 
5243-5237 to comply with the applicable VASRD. 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: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic Low Back Pain due to Degenerative Disc Disease with 
Bertolotti’s Syndrome 

5243-5237 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120606 w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 

 XXXXXXXXXXXXXXXXXX, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for XXXXXXXXXXXXXXXXXXX, AR20130006068 (PD201200686) 

 

 

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 description 
without modification of the combined rating or 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 XXXXXXXXXXXXXXXXXXXXXXXX 

 Deputy Assistant Secretary 

 (Army Review Boards)