RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200725 SEPARATION DATE: 20061128 

BOARD DATE: 20130402 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (13B/Cannon Crewmember), medically 
separated for chronic back pain. The CI injured his back in an improvised explosive device (IED) 
attack during his second deployment to Iraq in May 2005. He was evaluated, treated 
conservatively and placed on quarters for 2 weeks before returning to his duties. He again 
injured his back during an abrupt stop while serving in the .50 caliber gunner’s turret. He was 
treated and received physical therapy. He continued with his unit and re-deployed in early 
2006 where we was further evaluated and determined to have a compression fracture. He 
continued with conservative treatment but was unable to meet the physical requirements of 
his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a 
permanent L3S2 profile and referred for a Medical Evaluation Board (MEB). Posttraumatic 
stress disorder (PTSD), insomnia, subjective memory loss, history of bulimia, history of obesity, 
hyperlipidemia, chronic intermittent right wrist pain, and bilateral pes planus conditions, 
identified in the rating chart below were also identified and forwarded by the MEB. The 
Physical Evaluation Board (PEB) adjudicated the chronic back pain condition as unfitting, rated 
10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The 
remaining conditions were determined to be not unfitting. The CI made no appeals and was 
medically separated with a 10% disability rating. 

 

 

CI CONTENTION: “Disability was underrated existing symptoms at that time deserved a higher 
rating. Rating of 20% was assigned 2/15/2007 by Denver Colorado Veterans Affairs Regional 
Office. Currently going for a higher rating as veteran's condition has worsened.” 

 

 

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 conditions “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 back pain, as 
requested for consideration, meets the criteria prescribed in DoDI 6040.44 for Board purview 
and is 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 Military Records. 

 

 

 


RATING COMPARISON: 

 

Service PEB – Dated 20061004 

VA (<1 Month Post-Separation) – All Effective Date 20061001* 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Back Pain 

5299-5235 

10% 

Thoracolumbar Spondylosis and 
Compression Fracture T11 

5235 

20% 

20061205 

PTSD 

Not Unfitting 

PTSD with History of Mild Concussion 
Secondary to IED Explosion 

9411 

30% 

20061204 

Chronic Intermittent Right 
Wrist Pain 

Not Unfitting 

Tendonitis, Right Wrist 

5024 

10% 

20061205 

History of Bulimia 

Not Unfitting 

Bulimia Nervosa 

9521 

0% 

20061204 

Insomnia 

Not Unfitting 

NO VA ENTRIES 

 

Subjective Memory Loss 

Not Unfitting 

History of Obesity 

Not Unfitting 

Hyperlipidemia 

Not Unfitting 

Bilateral Asymptomatic 
Pes Planus 

Not Unfitting 

.No Additional MEB/PEB Entries. 

Sebaceous Hyperplasia of Nose and 
Dermatitis Face, Neck and Back 

7820-
7806 

30% 

20061205 

Combined: 10% 

Combined: 70% 



*The VA used an incorrect separation date; the correct separation date would have been 20061128. 

 

ANALYSIS SUMMARY: 

 

Chronic Back Pain Condition. There were three goniometric range-of-motion (ROM) 
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. 

 

Thoracolumbar ROM 

(Degrees) 

MEB ~3 Mo. Pre-Sep 

(20060826) p.49 

VA C&P 7 Days Post-Sep 

(20061205)p.165 

VA C&P ~12 Mo. Post-Sep 

(20071213)p.168 

Flexion (90 Normal) 

45 (65, 46, 43) 

65 

75 

Ext (30) 

20 (23, 21, 18) 

25 

20 

R Lat Flex (30) 

20 (20, 20, 17) 

20 

30 

L Lat Flex (30) 

30 (30, 31, 32) 

25 

30 

R Rotation (30) 

30 (23, 23, 36) 

30 

30 

L Rotation (30) 

30 (35, 42, 36) 

30 

30 

Combined (240) 

175 

185 

215 

Comments 

Limited by pain 

No muscle spasm 

Gait normal 

Muscle spasm with 
flexion 

Painful motion 

Gait normal 

§4.71a Rating 

20% 

10% 

10% 



 

The CI sustained a back injury in May 2005, while deployed to Iraq, when an IED exploded 
underneath his vehicle and he was thrown away. The CI reinjured his back a month later when 
his vehicle hit a large pothole and he was thrown forward. As the back pain increased, physical 
therapy was recommended and his activities were reduced to “radio watch” only, though he 
was not placed on a profile and completed his deployment. Following return to his home base, 
the CI was evaluated in the clinic in February 2006 for his back pain. The CI complained of slight 
non radiating lower back ache, intermittent and constant dull pain between shoulder blades. 
On examination there was muscle spasm with normal gait and normal neurologic examination. 
X-ray exam evidenced mild degenerative changes at the lower thoracic and upper lumbar spine 
as well as mild to moderate compression changes at T11-T12 and possibly L1 vertebral body. 
Magnetic resonance imaging (MRI) exam from June 2006 noted compression deformity of the 
T11 vertebral body and mild degenerative changes at the T11-T12 and T12-L1 levels with no 
spinal stenosis. A 26 April 2006 clinic examination noted muscle spasm with straightening of 
lumbar lordosis, but “no loss of range of motion of the back.” A 21 June 2006 clinic exam noted 


muscle spasm with loss of lordosis. A 14 July 2006 clinic examination recorded back flexion and 
extension was “normal.” As the pain was not alleviated by conservative treatment, a 
permanent profile was issued and MEB was recommended. The MEB narrative summary 
(NARSUM) examination on 29 August 2006, 4 months prior to separation, noted the CI reported 
constant pain in his mid upper back, radiating into his lower neck and lower back, five out of 
ten in intensity. He denied any radicular symptoms but acknowledged occasional pain in the 
posterior/inferior aspect of his right shoulder after increased activity. Physical exam revealed 
tenderness to palpation around T5-L1 levels with no muscle spasm. Back range-of-motion 
(ROM) was limited by pain per the chart. At the VA Compensation and Pension (C&P) 
examination on 5 December 2006, 7 days after separation, the CI continued to complain of 
upper and lower back pain rated six-seven out of ten without radicular pain, neurologic 
symptoms of the lower extremities or associated bladder dysfunction. The CI complained of 
inability to walk for more than 20 minutes or play lacrosse. The examiner mentioned one 
incapacitating episode of lumbar pain over the previous 12 months with 2 day duration. ROM 
was limited per the chart. Repetitive movement elicited mid back pain but no fatigability, 
incoordination or reduction in ROM. The physical exam did not evidence focal tenderness or 
abnormal spinal contour and gait was normal. On forward bending the examiner noted 
conspicuous paralumbar muscle spasm and reduced lumbar lordosis. Neurological exam 
including deep tendon reflexes (DTRs) and muscle bulk and strength was normal. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB rated the back pain condition 10% analogous to code 5235, vertebral fracture or 
dislocation. The VA rated the thoracolumbar condition under the same 5235 code but assigned 
a rating of 20% citing flexion of the thoracolumbar spine limited to 60 degrees. While the VA 
rater assigned a 20% disability rate based on thoracolumbar spine flexion limited to 60 degrees, 
actual exam notes evidenced that flexion was 65 degrees without further reduction with 
repetition, which would warrant a disability rating of 10%. While there was muscle spasm with 
flexion, the examiner’s observation of a loss of lordosis with flexion occurs with normal flexion 
and indicates normal lumbar spine mobility despite the apparent muscle spasm. The Board 
noted the limitation of thoracolumbar motion from the MEB NARSUM supported consideration 
of a 20% rating however examinations in April and July 2006 recorded normal range of motion. 
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 adjudication for the chronic 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. The Board did not 
surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD 
were exercised. In the matter of the chronic back pain condition and IAW VASRD §4.71a, the 
Board unanimously recommends no change in the PEB adjudication. 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 

Chronic Back Pain 

5299-5235 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120516, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
xxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130009556 (PD201200725) 

 

 

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 xxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)