RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201014 SEPARATION DATE: 20030630 

BOARD DATE: 20130222 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (91W/Medical Specialist), medically 
separated for chronic low back pain (LBP). His lumbosacral symptoms, initially intermittent, but 
eventually constant, did not improve with conservative therapy, and his condition could not be 
adequately rehabilitated in order for him to meet the physical requirements of his Military 
Occupational Specialty or to satisfy physical fitness standards. He was issued a permanent 
L3/E2 profile and referred for a Medical Evaluation Board (MEB). The Physical Evaluation Board 
(PEB) adjudicated the low back condition as unfitting, rated 10%, with application of the 
Veterans Affairs Schedule for Rating Disabilities (VASRD). Additionally, bilateral lower extremity 
varicose veins, left varicocele, pes planus and vision defect, identified in the rating chart below, 
were also identified and forwarded by the MEB as conditions which met retention standards 
and were determined to not be unfitting. The CI made no appeals, and was medically 
separated with a 10% disability rating. 

 

 

CI CONTENTION: “I have to take medication for my back to relieve the pain. I believe these 
medications are causing seizures which makes driving impossible. These medications are 
oxycodone, Xanax, Ambien, Adderall and Prozac. I take Prozac for depression.” 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 ratings 
for unfitting conditions will be reviewed in all cases. The varicose veins, varicocele, pes planus 
and vision defect conditions were not alluded to in the application, and are not judged to have 
been requested; e.g., they do not satisfy scope requirements. The other conditions (seizures 
and depression) 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 IPEB – Dated 20030528 

VA (1 Mos. Post-Separation) – All Effective Date 20030701 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Low Back Pain/DDD 

5295 

10% 

DDD Lumbar Spine 

5010-5292 

20% 

20030724 

BLE varicose vein 

Not Unfitting 

Varicose Veins LLE 

7120 

10% 

20030724 

Varicose Veins RLE 

7120 

10% 

20030724 

Varicocele 

Not Unfitting 

Varicocele 

7599-7120 

NSC 

20030724 

Vision Defect 

Not Unfitting 

Bilateral Peripheral Retinal Deg 

6099-6011 

0% 

20030724 

Pes Planus 

Not Unfitting 

B Pes Planus 

5276 

NSC 

20030724 

.No Additional MEB/PEB Entries. 

0% X 1 / Not Service-Connected x 3 

20030724 

Combined: 10% 

Combined: 40% 



 


ANALYSIS SUMMARY: 

 

Chronic Low Back Pain Condition. The MEB narrative summary (NARSUM) notes intermittent 
and recurrent LBP during a previous enlistment. Shortly after re-enlistment, he reported LBP, 
without antecedent trauma, on 18 May 2001, which flared intermittently. Pain gradually 
became constant. Magnetic resonance imaging (MRI) performed on 11 October 2002 revealed 
degenerative disc disease (DDD) at L4 through S1, and a L5 posterolateral disc protrusion 
contacting the left L5 nerve root. Pain specialist 9 December 2002 read the MRI as normal. 
Surgery was not recommended. Treatment including chiropracty, medications, physical 
therapy and therapeutic injections, provided only brief and transient relief. Service treatment 
records (STRs) reveal periodic visits for LBP, exacerbated by mild activity, such as lifting tent 
poles or twisting, and without radiation of symptoms suggesting radiculopathy. There is no 
documentation of any incapacitating episodes. There were two goniometric range-of-motion 
(ROM) examinations with documentation of additional ratable criteria, which the Board 
weighed in arriving at its rating recommendation, as summarized in the following chart: 

 

Thoracolumbar ROM 

(Degrees) 

MEB ~3 Mo. Pre-Sep 

(20030326) 

VA C&P ~<1 Mo. Post-Sep 

(20030724) 

Flexion (90 Normal) 

75 

80 

Extension (30) 

15 

10 

R Lat Flex (30) 

25 

30 

L Lat Flex (30) 

20 

30 

R Rotation (30) 

25 

- 

L Rotation (30) 

25 

- 

Comment 

Tender to pressure; 
without palpable spasm; 
no visible deformity 

Pain w/extension 

Gait normal 

SLR negative 

Strength normal 

§4.71a Rating 

10% 

10% 



 

At the MEB exam, the CI reported constant LBP, aggravated by running, bending, lifting, 
twisting, and standing longer than 30 minutes. His pain was exacerbated with lumbar extension 
and intermittently was relieved by sitting or lying down, and was accompanied by no radicular 
symptoms. He had been prescribed non-narcotic and narcotic analgesic medications. The MEB 
physical exam 26 March 2003 noted that a physical examination revealed tenderness to 
pressure (TTP) at the lumbosacral junction, without evidence of muscles spasm, weakness or 
sensory deficit. ROM is recorded in the chart. At the VA Compensation and Pension (C&P) 
exam on 24 July 2003, the CI reported pain “at the top of his buttocks,” especially after standing 
for long periods. Upon examination, the straight leg raising (SLR) test was negative, strength 
testing was normal and no sensory abnormalities were noted. ROM on this occasion is 
recorded above. Gait was not recorded but at the 6 August 2003 C&P examination 2 weeks 
later, gait was reported as normal. 

 

The Board directs attention to its rating recommendation based on the above evidence. In 
accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in 
effect at the time of separation. The Board notes that the 2003 VASRD standards for the spine, 
which were in effect at the time of separation, were changed to the current §4.71a rating 
standards in 2004. The Board must correlate the above clinical data with the 2003 rating 
schedule, and its applicable diagnostic codes including 5292 (limitation of lumbar spine 
motion), 5293 (intervertebral disc syndrome) and 5295 (lumbosacral strain). The PEB rated the 
back pain condition 10% coded 5295, lumbosacral strain. The VA rated his condition at 20%, 
coded 5010-5292, citing moderate limitation of lumbar motion. The Board first considered the 
rating under code 5292 (limitation of lumbar spine motion). All Board members agreed the 
limitation of motion on both examinations did not approach the moderate level and more 
nearly approximated the slight level with a 10% rating. Since the CI’s diagnosis at the MEB had 


been “herniated nucleus pulposus,” the Board then considered whether a higher rating would 
be warranted under the Rating Code 5293 “Intervertebral Disc Syndrome.” Although there was 
documented disc disease, there were no signs, symptoms or objective findings for 
radiculopathy. Additionally, there was no documentation of incapacitating episodes to support 
a minimum rating under the 5293 code guidelines in effect at the time of separation. Finally, 
the Board considered the rating under the VASRD diagnostic code 5295 used by the PEB. All 
members agreed that the symptoms and examination, including ROM, supported a rating of 
10%, but concluded that the preponderance of evidence did not support a higher rating than 
the 10% assigned by the PEB. After due deliberation, 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 chronic lumbosacral 
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 
lumbar spine 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 

Lumbar Spine: Herniated Nucleus Pulposus 

5295 

10% 

RATING 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120610, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review