RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201409 SEPARATION DATE: 20030911 

BOARD DATE: 20130315 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty Specialist/E-4 (55B10/Ammunition Supply Specialist), 
medically separated for chronic mechanical low back pain (LBP), without neurologic 
abnormality or documented chronic paravertebral muscle spasms on repeated examinations, 
with characteristic pain on motion. The CI first presented for her mechanical LBP in June 2001, 
after lifting a rocket. The condition did not resolve with conservative therapy. The CI could not 
be adequately rehabilitated to meet the physical requirements of her Military Occupational 
Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent P2/L3 profile 
and was referred for a Medical Evaluation Board (MEB). The MEB forwarded no other 
conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated LBP condition 
as unfitting, rated 10%, with cited application of the Department of Defense Instruction (DoDI) 
1332.39, AR 635-40, Appendix B-39, and the Veteran’s Affairs Schedule for Rating Disabilities 
(VASRD). The CI made no appeals, and was medically separated with a 10% disability rating. 

 

 

CI CONTENTION: The CI makes no contentions. 

 

 

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, 
paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for 
continued military service and those conditions identified but not determined to be unfitting by 
the PEB when specifically requested by the CI. The ratings for unfitting conditions will be 
reviewed in all cases. 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 20030911 

VA (3 Mos. Post-Separation) – All Effective Date 20030912 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic MLBP w/o Neurologic 
Abnormality or Muscle Spasm, w/ 
Pain on Motion 

5299-5295 

10% 

Low Back Injury With 
Chronic Myofascial Pain 

5295 

10% 

20031219 

Combined: 10% 

Combined: 10% 



 

 

ANALYSIS SUMMARY: 

 

Chronic Mechanical Low Back Pain. The CI first noted LBP on 10 July 2001 after lifting a 160 
pound rocket with another soldier in June 2001. On that occasion, the CI described the pain as 
sharp, constant, 9/10 and that it kept her up at night. Service treatment records (STR) 
document tenderness to palpation in the paralumbar muscles, right greater than left, but 
posture, gait, strength, sensation, reflexes, and range-of-motion (ROM) were normal. Straight 
leg raise (SLR) test was negative. Treatment with medications, physical therapy and 
chiropractic care provided no benefit. Lumbar spine X-rays taken 14 February 2002 were 


normal. Magnetic resonance imaging (MRI) of the lumbar spine obtained 21 August 2002 
revealed a “miniscule disc herniation posterior midline” at L4-5, which did not touch any nerve 
roots. Except for some pain radiating into both buttocks, there was no evidence of 
radiculopathy, and no incapacitating episodes were documented. The 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. 

 

Lumbar ROM 

(Degrees) 

MEB ~ 2 Mo. Pre-Sep 

(20030710) 

VA C&P ~ 3 Mo. Post-Sep 

(20031219) 

Flexion (90 Normal) 

“nearly” 90 

80 

Extension (30) 

15 

25 

R Lat Flexion (30) 

30 

25 

L Lat Flexion (30) 

30 

25 

R Rotation (30) 

50 

25 

L Rotation (30) 

50 

25 

§4.71a Rating 

10% 

10% 



 

The MEB physical examination on 14 March 2002 (DD Form 2808) documents that the entry for 
“spine” is checked as “normal.” At the time of her MEB narrative summary (NARSUM), 9 May 
2003, the CI noted, “I can’t sit or stand for long periods of time because of my back.” Her 
symptoms were noted as bilateral paralumbar pain, described also as “pins and needles,” 
“frequent and slight,” worse with standing and lifting, and relieved by rest. There was no 
indication of radiculopathy, neither weakness nor paresthesia. The MEB NARSUM examination 
did not address the presence or absence of muscle spasm or tenderness, although previous 
clinic examinations on 27 March 2002, 8 April 2002 and 17 May 2002 repeatedly noted 
tenderness. An addendum to the MEB, dated 10 July 2003, documented negative SLR test 
bilaterally, normal sensation and strength in lower extremities, normal reflexes, normal heel 
and toe walk, no muscle atrophy, and range of motion as described in the table. At the VA 
Compensation and Pension (C&P) exam on 19 December 2003, 3 months after separation, the 
CI reported paraspinal pain radiating into the buttocks, without “giving way,” and without loss 
of bladder or bowel control. The VA examination noted normal gait, mild tenderness to 
palpation in the mid lumbar region, right greater than left, “tenderness to palpation over the 
right sciatic notch.” This examination documented normal deep tendon reflexes, and normal 
motor and sensory examination without muscle wasting in the lower extremities. ROM is noted 
in the table above. Pain at 80 degrees of forward flexion was documented. MRI performed by 
the VA on 5 January 2004 revealed “no significant degenerative disc disease, no significant 
canal or neuroforaminal stenosis,” and “moderate degenerative facet disease of the mid to 
lower lumbar spine,” more prominent on the right. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB rated the chronic mechanical LBP 10% under the VASRD code for lumbar strain in effect at 
the time citing characteristic pain on motion without neurologic abnormality or documented 
chronic paravertebral muscle spasms on repeated examinations. The VA rated the back 
condition (“low back injury with chronic myofascial pain”) 10% (coded 5295) citing 
characteristic pain on motion, noting that her condition did not meet criteria for 20% due to 
absence either of “muscle spasm on extreme forward bending” or “unilateral loss of lateral 
spine motion.” 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 Veteran 
Administration Schedule for Rating Disabilities (VASRD) standards for the spine, which were in 
effect at the time of separation, were changed to the current §4.71a rating standards effective 
27 September 2003, 2 weeks after the CI separated from the military. Therefore, the Board 
must correlate the above clinical data with the earlier 2003 rating schedule. The applicable 
diagnostic codes include 5292 (limitation of lumbar spine motion), 5293 (intervertebral disc 
syndrome), and 5295 (lumbosacral strain). The Board first considered the rating under the 


VASRD diagnostic code 5292 in effect at the time. At the MEB examination, except for slight 
limitation of extension ROM was normal. The C&P examination documented mild limitation of 
motion more nearly approximating the 10% rating under code 5292. All members agreed there 
was no evidence to support a higher rating than the 10% adjudicated by the PEB based on 
limitation of motion. The Board next considered whether a higher rating was warranted under 
the guidelines for intervertebral syndrome, code 5293. Although an MRI indicated the 
presence of slight disc herniation, there was no involvement of nerve structures and the CI did 
not display any of the symptoms, signs, or examination findings of an intervertebral disc 
syndrome. Regardless, there was no documentation of any incapacitating episodes required for 
rating under code 5293. The Board also considered the rating under code 5295, lumbosacral 
strain, which had been chosen by both the PEB and VA. There was no documented muscle 
spasm or loss of lateral motion which qualified for a rating of 20% under this code. 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 mechanical low back 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. As discussed above, PEB 
reliance upon AR 635-40 and DoDI 1332.39 for rating 10% was operant in this case, but the 
condition was adjudicated independently of those policies and instructions by this Board. In 
the matter of the chronic mechanical low back 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 Low Back Pain Condition 

5299-5295 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120605, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 

xxxxxxxxxxxxxxxxxxxxxxxxx, 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 xxxxxxxxxxxxxxxxxx, AR20130005503 (PD201201409) 

 

 

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 xxxxxxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)