RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201395 SEPARATION DATE: 20020715 

BOARD DATE: 20130118 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC, E-4 (MOS 92G10/Food Service Specialist), 
medically separated for a mechanical low back pain (LBP) condition. The CI could not be 
adequately rehabilitated to meet the physical requirements of his Military Occupational 
Specialty MOS. He was consequently issued a permanent L3 profile and referred for a Medical 
Evaluation Board (MEB). The chronic mechanical LBP condition was forwarded to the Physical 
Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. No other conditions were 
submitted by the MEB to the PEB. The PEB adjudicated the chronic mechanical LBP condition 
as unfitting, rated 10%, citing criteria of the Veterans Administration Schedule for Rating 
Disabilities (VASRD). The CI made no appeals, and was medically separated with a combined 
10% permanent disability rating. 

 

 

CI CONTENTION: “When I received a medical discharge I was service connected (sic) disability 
for degenerative disc disease of the lumbar spine. My current disability states that I have a 
herniated nucleus pulposus (sic) of the L4-L5, with secondary stenosis and radiculopathy of the 
lower right extremity. At the time of my seperation (sic) I explained to the Doctor that both my 
knees hurt but my right knee hurts more than my left knee. My medical VA records indicate 
that I received surgery on my left knee, when the Doctor from Ortho placed a request for 
temporary 100% disability it was denied due to non-service connection for my left knee (sic) 
Medical Discharge Doctor did not indicate that both knees were affected only right knee which I 
still have pain. I am also service connected for muscle tension headaches. I was sent numerous 
(sic) sleep studies and was diagnosed with sleep apnea and use of a CPAP, and underwent 
surgery UPPP and I am currently sending a claim for sleep apnea. I feel my headaches are 
related to my sleep apnea. I have pain in my right shoulder which flairs up and cannot move my 
neck for days. When pain is extremely bad I receive a steroid shot in my shoulder.” 

 

 

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in 
Department of Defense Instruction (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 rating for the CI’s unfitting mechanical LBP condition is addressed below. The 
lower right extremity radiculopathy, bilateral knee pain, muscle tension headaches, sleep 
apnea, and right shoulder pain conditions specified in the application were not identified or 
adjudicated by the PEB and thus are not within the purview of the board. 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 service Board for Correction of Military 
Records. 

 


 

RATING COMPARISON: 

 

Service IPEB – Dated 20020606 

VA (~at Separation) – Effective 200200716 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Mechanical Low Back Pain 

5295 

10% 

Low Back Sprain 

5292 

20% 

20020709 

.No Additional MEB/PEB Entries. 

Chondromalacia Patellae of the 
Right Knee 

5299-5260 

10% 

20020709 

0% X 3 

20020709 

Combined: 10% 

Combined: 30% 



 

 

ANALYSIS SUMMARY: 

 

Mechanical Low Back Pain Condition. According to the MEB narrative summary (NARSUM), the 
CI had a 2 year history of back pain without a particular inciting injury. On a physical therapy 
(PT) note dated 11 June 2001, 12 months prior to separation, non-compliance with a prior 
treatment plan was noted. During that visit, the CI stated his command wanted him to get a 
medical board. On another PT note dated 6 July 2001, a long history of non-compliance was 
noted since December 2000. At a physical medicine evaluation on 26 June 2001, 12 months 
prior to separation, the CI reported gradually progressing pain for a year with occasional 
radiation to the left thigh and calf. Pain was reported as severe and exacerbated by activity. 
On examination, flexion was near normal with ability to reach the fingers to the mid tibia (shin). 
Extension and lateral bending was slightly reduced (20 degrees each) with normal rotation (45 
degrees both sides). A positive straight leg rise (SLR) and Lesegue’s sign were found on the left 
leg with pain radiating to the left calf, however there was normal motor, sensory, and reflexes 
noted. At the medical evaluation board exam documented in the MEB NARSUM performed on 
13 May 2002, 2 months prior to separation, the CI stated he had pain after standing for 
prolonged periods of time, lifting, bending, and twisting, and occasional pain radiating to his left 
anterior thigh and heel. He was unable to participate in physical training or work in his MOS. 
He was taking no medications for the LBP condition at the time. On examination flexion was 
moderately reduced with the CI reaching fingers to mid thigh and motion was moderately 
limited in all directions with report of pain. There was report of pain with two examination 
maneuvers not expected to cause pain. There was mildly decreased left toes, first web space 
and lateral malleolus sensation. Normal strength, normal reflexes, and a negative (SLR) test 
were noted. X-ray findings on 19 June 2002 showed a normal lumbar spine. At the VA 
Compensation and Pension (C&P) exam on 7 September 2002, a week prior to separation, the 
CI reported pain on a daily basis, worsening with standing and bending, with occasional 
radiation to the legs. On examination, flexion of 30 degrees was recorded with report of pain. 
Additionally, findings of tenderness, paraspinous muscle spasm, positive SLR, and antalgic gait 
were noted. Muscle strength was 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 2002 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 2002 rating 
schedule (applicable diagnostic codes include: 5292 limitation of lumbar spine motion, 5293 
intervertebral disc syndrome; and 5295 lumbosacral strain). The Board considered VASRD 
diagnostic code 5295 used by the PEB to adjudicate the condition at 10%. The Board could not 


find clinical evidence to meet the 40% rating criteria of listing, positive Goldthwaite’s sign, 
marked limitation of forward bending, osteoarthritic changes, narrowing or irregular joint 
spaces, or abnormal mobility on forced motion. The Board agreed that the record supported 
the 20% rating criteria finding evidence of muscle spasm, and loss of lateral spine motion in the 
VA C&P examination cited above. The Board considered the code used by the VA, 5292 
limitation of motion of lumbar spine. The Board found the evidence did not support the severe 
40% rating. The Board agreed that the limitations of motion cited in the medical record, as well 
as the functional limitations imposed by profiles were more than slight and at the moderate 
range thus achieving a 20% rating. The intervertebral disc syndrome code 5293 was also 
considered by the Board. Evidence in the service records indicated the CI’s LBP condition did 
not achieve a more favorable rating for the CI under this diagnostic code. There was no 
evidence of ratable peripheral nerve impairment or documentation of incapacitating episodes 
which would provide for additional or higher rating. After due deliberation, considering all of 
the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a 
disability rating of 20% for the mechanical LBP 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 mechanical LBP condition, the Board recommends by a 
vote of 2:1 a disability rating of 20%, coded 5295, IAW VASRD §4.71a. The single voter for 
dissent (who recommended no recharacterization) did not elect to submit a minority opinion. 
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 

Mechanical Low Back Pain Condition 

5295 

20% 

COMBINED 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120711, w/atchs. 

Exhibit B. Service Treatment Record. 

Exhibit C. Department of Veterans’ Affairs Treatment Record. 

 

 

 

 

 

 XXXXXXXXXXXXXXXXXXXXXX, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for XXXXXXXXXXXXXXXXXXX, AR20130003943 (PD201201395) 

 

 

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 xxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)