RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201489 SEPARATION DATE: 20031016 

BOARD DATE: 20130117 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SGT/E-5 (55B/Ammunition Specialist), medically 
separated for chronic low back pain (LBP). The CI failed conservative treatment to include 
medications, physical therapy (PT), chiropractic care and temporary profiles. The chronic LBP 
condition could not be adequately rehabilitated and did not improve adequately with 
treatment 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 no other conditions for Physical 
Evaluation Board (PEB) adjudication. The PEB adjudicated the chronic LBP condition as 
unfitting, rated 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities 
(VASRD) and cited application of DoDI 1332.39 and AR 635-40. The CI made no appeals, and 
was medically separated with a 10% disability rating. An administrative change was made to 
item 10 of the original PEB determination, and the overall rating was not changed from 10%. 

 

 

CI CONTENTION: “Chronic lower back pain degenerative muscle damage in back, Plantar 
Fasciitis in both feet, Chronic arthritis in left ankle due to break in tibia/fibia. (sic)” 

 

 

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 unfitting condition chronic LBP as 
requested for consideration meets the criteria prescribed in DoDI 6040.44 for Board purview; 
and, is addressed below. The other requested conditions of plantar fasciitis, and chronic 
arthritis in left ankle 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 service Board for Correction of Military Records. 

 

 

RATING COMPARISON: 

 

Service Admin Correction – Dated 20030709 

VA (16 mons pre-sep) – All Effective Date 20031017 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Low Back Pain 
without Neurologic 
Abnormality 

5299-5295 

10% 

Low Back Strain (also Claimed as 
Mechanical LBP and HNP) 

5237 

10% 

20020628 

.No Additional MEB/PEB Entries. 

Residual, Left Ankle Fracture 
Postoperative with Scar and DJD 
and Decreased Range of Motion 

5010-5271 

10% 

20020628 

0% X 2 

 

Combined: 10% 

Combined: 20% 



 

 

ANALYSIS SUMMARY: The Board acknowledges the CI’s contention that suggests ratings should 
have been conferred for other conditions documented at the time of separation. The Board 


wishes to clarify that it is subject to the same laws for service disability entitlements as those 
under which the Disability Evaluation System (DES) operates. While the DES considers all of the 
member's medical conditions, compensation can only be offered for those medical conditions 
that cut short a member’s career, and then only to the degree of severity present at the time of 
final disposition. However the Department of Veterans Affairs, operating under a different set 
of laws (Title 38, United States Code), is empowered to compensate all service-connected 
conditions and to periodically reevaluate said conditions for the purpose of adjusting the 
Veteran’s disability rating should the degree of impairment vary over time. 

 

Chronic Low Back Pain Condition: The CI had a several year history of non-traumatic, non-
radiating LBP which failed to resolve or improve with vigorous conservative treatment 
modalities to include chiropractic care and local steroid injections. The CI had no long-term 
resolution of his symptoms. Radiological imaging of the lumbar spine plain films (dated 
October 1995, February and August 2002) and magnetic resonance imaging (MRI) scans (dated 
November 1993 and January 2003) were normal. 

 

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 

(degrees) 

VA C&P ~16 Mos. Pre-
Sep 

Chiro ~11 Mos. Pre-
Sep 

PT ~7 Mos. Pre-
Sep 

MEB ~5 Mos. Pre-
Sep 

Flexion (90 Normal) 

90 (45) 

70 

60 

50 

Ext (0-30) 

30 (15) 

20 

30 

10 

R Lat Flex (0-30) 

35 

35 

15 

10 

L Lat Flex 0-30) 

35 

35 

15 

10 

R Rotation (0-30) 

30 (20) 

25 

- 

30 

L Rotation (0-30) 

30 

20 

- 

30 

Combined (240) 

250 

205 

 

140 

Comment: VA 
normal ROMs 
effective 20030926 

(#) = begins painful ROM; 
limp 

tender; painful 
motion; spasm 

tender; painful 
motion 

tender; spasm; 
painful limited ROM 

§4.71a Rating 

10% 

10% 

20% 

20% 



Note: ROM data measurements are in degrees 

 

At the MEB exam, the CI reported having continued progressive worsening of mid to LBP 
described as mostly non-radiating with a daily pain rated at 5/10. The MEB physical exam 
noted tenderness, spasm, and painful ROM to the lumbar spine as summarized above. 
Treatment notes indicated episodic spasms, pain-limited ROMs, and abnormal gait. 

 

At the VA Compensation and Pension (C&P) exam, the CI reported progressive LBP rated at 
7/10 every other day with performing normal daily activities. Examination revealed normal, but 
painful ROM as summarized in the exam chart above. There was no VA exam proximate to the 
date of separation (DOS). Post-separation VA exam accomplished in 2006, over 2 years remote 
from separation was rated by the VA at 10%. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB coded the back condition utilizing the 2002 VASARD rating rules as 5299-5295, analogous 
to lumbosacral strain and citing DoDI 1332.39 and AR 635-40. The VA exams for rating at 10% 
were over 12 months remote from separation. The chiropractic exam 11 months prior to 
separation was unclear (hand-written) if there was muscle spasm. The Board considered it 
most likely to reflect spasm given other non-charted positive chiropractic tests. Additionally, 
the Board unanimously concurred that the forward flexion on the hand-written examination 7 
months prior to separation was indeed 60 degrees versus 80 degrees. Upon deliberation, the 
Board agreed in this case that the MEB examination had the highest probative value for rating 


at the time of separation and was supported by treatment records indicating additional 
episodes of spasm and abnormal gait in the year preceding separation. 

 

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable 
doubt) and §4.7 (higher of two evaluations), the Board recommends a disability rating of 20% 
for the low back condition and change of VASRD code to 5237 to comply with the VASRD in 
effect at the time 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, and the older VASRD for rating the low back condition 
was operant in this case and the condition was adjudicated independently of those instructions 
and with the applicable VASRD by the Board. In the matter of the chronic LBP condition, the 
Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a. 
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 

Lumbosacral strain 

5237 

20% 

COMBINED 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120816, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 

 XXXXXXXXXXXXXXXX, 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 XXXXXXXXXXXXXXXX, AR20130003893 (PD201201489) 

 

 

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 XXXXXXXXXXXXXXXX 

 Deputy Assistant Secretary 

 (Army Review Boards)