RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200509 SEPARATION DATE: 20011115 

BOARD DATE: 20130115 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (71L10/Administrative 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. Despite orthopedic and physical therapy evaluations and 
medication, the CI was unable to perform his duties or meet the physical fitness standards. The 
CI was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The 
MEB forwarded chronic LBP, nonradicular in nature; pain is moderate and frequent. The MEB 
forwarded no other conditions for Informal Physical Evaluation Board (IPEB) adjudication. The 
IPEB adjudicated the chronic mechanical LBP as unfitting rated 10% with application of the 
Veterans Affairs Schedule for Rating Disabilities (VASRD), Department of Defense Instruction 
(DoDI) 1332.39, and AR 635-40 Appendix B-39. The CI appealed to a Formal PEB (FPEB) asking 
to be found fit for continued service. The FPEB affirmed the iPEB findings and the CI was then 
medically separated with a 10% disability rating. 

 

 

CI CONTENTION: “I am constantly having severe back pains & problems each and every day 
[SP], I take medications daily for pain and muscle spasms (CycloBENZaprine, Meloxicam & 
Motrin). I have heating pads and a back brace which is a temporary relief. I am not able 
participate in family events with my kids and family. This causes depression and sadness to not 
be able to participate in family events and functions. By not being able to exercise regularly, 
like I normally did in the US Army, I now have Diabetes Type 2. I have been having the 
symptoms with fatigue, irritations, eye sight, slow to heal, etc. But, however I was not 
diagnosed with Diabetes until 2008. My Medical records does [sic] not show adequate Lab 
work for signs of Diabetes. I currently have 20% Disability for Back Problems and 10% for my 
Alopecia. I have a total of 30% Disability.” 

 

 

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 chronic mechanical LBP 
condition meets the criteria prescribed in DoDI 6040.44 for Board purview and is addressed 
below. The requested conditions of depression; Diabetes Type 2 with fatigue, irritations, eye 
sight, slow to heal, etc.; and alopecia are not within the Board’s purview. The remaining 
conditions rated by the VA at separation and listed on the DD Form 294 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 FPEB – Dated 20010905 

VA (~5 Months Post-Separation) – All Effective Date 20011116 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Mechanical Low 
Back Pain 

5299-5295 

10% 

Degenerative Disc Disease, 
Lumbosacral Spine at L4-5 with 
Recurrent Lumbosacral Strain 

5295 

20% 

20020404 

.No Additional MEB/PEB Entries. 

Alopecia of Scalp 

7899-7816 

10%* 

20020404 

Not Service-Connected x 5 

Combined: 10% 

Combined: 30%** 



*Initially rated as 7830 at 0% then increased per Decision Review Officer Decision to 7899-7816 at 10% effective 20011116. 

**Initially 20% but then increased per Decision Review Officer Decision to 30% with increase of alopecia rating effective 
20011116. 

 

 

ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating 
the fairness of Disability Evaluation System fitness determinations and rating decisions for 
disability at the time of separation. The Board utilizes VA evidence proximal to separation in 
arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special 
consideration to post-separation evidence. Post-separation evidence is probative only to the 
extent that it reasonably reflects the disability and fitness implications at the time of 
separation. 

 

Chronic Mechanical Low Back Pain Condition. There were three 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 

PA ~7.5 Months 

Pre-Separation 

MEB ~6 Months 

Pre-Separation 

VA C&P ~5 Months 

Post-Separation 

Flexion (90° Normal) 

Decreased ROM 

“Fingertips to knees with some 
pain” 

55° 

Ext (0-30) 

20° 

10° 

R Lat Flex (0-30) 

Not measured 

0-10° 

L Lat Flex 0-30) 

0-15° 

R Rotation (0-30) 

0-10° 

L Rotation (0-30) 

0-15° 

Combined (240°) 

 

 

115° 

Comment 

Tenderness to 
palpation 
paraspinal 
muscles; negative 
straight leg raise; 
strength 5/5; 
normal sensation 

Motor 5/5; sensation intact to 
light touch; symmetric 2+/4 
deep tendon reflexes 
bilaterally; some pain with 
pivot rotation of spine; no 
tenderness to palpation; no 
pain with Faber’s sign; negative 
straight leg raise; no pain with 
axial compression; and no 
overreaction; Waddell’s 0/5 
positive 

Gait normal; back midline; tender to 
palpation in the paravertebral muscles on 
left; slight spasm lower lumbar area; pain 
with ROM to left lumbar area; straight leg 
raise negative for radicular symptoms; 
reflexes 2+; heel/toe intact; motor and 
sensation intact; lower extremity ROM 
guarded but intact; Patrick’s and 
Goldthwaite tests negative; significantly 
greater range of motion noted when CI not 
under direct examination 

§4.71a Rating 

 

 

 

5295 

10% 

10% 

20% 

5292 

10% 

10% 

20% 



 

There were numerous notes in the service treatment record that documented the LBP 
condition from December 1999 through April 2001. In 1996 a lumbar spine X-ray noted a 


moderate degree of lumbar spine dextroscoliosis. The CI continued with the LBP and a repeat 
lumbar spine X-ray found a right L5 spondylolisthesis with early degenerative changes at T12-L1 
and L2-4. The CI underwent a third set of lumbar spine X-rays in October 2000 which showed 
mild L4-5 degenerative disc changes. Magnetic resonance imaging performed on 31 October 
2000 noted mild degenerative disc disease at L4-5 with a mild bulge in the cal sac and no 
stenosis at any level. The CI was seen by a physician assistant in April 2001, approximately 7 
months prior to separation, and was noted to have had pain when standing for long periods. 
The physical exam findings are summarized in the chart above. The MEB narrative summary 
(NARSUM) examination approximately 6 months prior to separation indicated a lack of benefit 
from, an inability to run or do sit-ups, pain with riding in a tactical vehicle, and an inability to sit 
for longer than an hour, as well as pain with long periods of carrying a load bearing equipment. 
His pain was noted to be moderate and frequent. The examiner opined that there were no 
radicular symptoms and no indications for surgery. The NARSUM physical exam findings are 
summarized in the chart above. The VA Compensation & Pension (C&P) examination 
performed approximately 4 months after separation noted that the CI continued with chronic 
LBP, early morning stiffness, pain upon walking that lasted approximately 2 hours and resolved 
with medications, and back discomfort that was aggravated by stair climbing. The C&P exam 
findings are summarized in the chart above. The CI appealed for an increased rating for his 
back pain four times from October 2005 to October 2009, but thoracolumbar flexion remained 
between 40 and 50 degrees; therefore the 20% rating was continued by the VA through April 
2010, the time of the most recent VA rating decision available for review. 

 

The 2001 VASRD coding and rating standards for the spine, were in effect at the time of 
separation, and then changed to the current §4.71a rating standards on 26 September 2003. 
The 2002 standards for rating based on ROM impairment were subject to the rater’s opinion 
regarding degree of severity, whereas the current standards specify rating thresholds in 
degrees of ROM impairment. When older cases have goniometric measurements in evidence, 
the Board reconciles (to the extent possible) its opinion regarding degree of severity for the 
older spine codes and ratings with the objective thresholds specified in the current VASRD 
§4.71a general rating formula for the spine. This promotes uniformity of its recommendations 
for different cases from the same period and more conformity across dates of separation, 
without sacrificing compliance with the DoDI 6040.44 requirement for rating IAW the VASRD in 
effect at the time of separation. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
FPEB coded the chronic mechanical LBP condition as analogous to 5295 and assigned 10% rating 
based on characteristic pain on motion. The VA coded the degenerative disc disease condition 
as 5295 rated at 20% based on muscle spasm on extreme forward bending, loss of lateral spine 
motion, unilateral, in standing position. The Board noted that both the PEB and VA 
examinations were sufficiently documented in terms of ratable data for the criteria in place at 
the time of their rating determinations. While the C&P examination was completed closer in 
time to the date of separation, it was completed after separation. The C&P exam also includes 
an indication of doubt regarding the actual ROM limitations as the CI was noted to have a 
significantly greater ROM of this thoracolumbar spine when he was not being directly 
examined. Therefore, greater probative value is assigned to the NARSUM examination that 
noted no positive Waddell’s signs. While ROM measurements were not required, the NARSUM 
examination does document some limitation of motion of the thoracolumbar spine and pain 
with motion. With no muscle spasm and only a slight limitation of motion, a rating greater than 
10% with either 5292 or 5295 is not warranted. 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 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. As discussed above, PEB 
reliance on DoDI 1332.39 VASRD and AR635-40 Appendix B-39 for rating the chronic 
mechanical LBP was operant in this case and the condition was adjudicated independently of 
these documents by the Board. In the matter of the chronic mechanical LBP condition, 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 Mechanical Low Back Pain 

5299-5295 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120604, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 President 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 
for xxxxxxxxxxxxxxx, AR20130001620 (PD201200509) 

 

 

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 xxxxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)