RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201096 SEPARATION DATE: 20030904 

BOARD DATE: 20130228 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (92G10/Food Service Specialist), medically 
separated for mechanical lower back pain secondary to congenital vertebral anomaly (spinal 
bifida) with characteristic pain on motion. He had low back pain (LBP) for 6 to 7 years that 
progressively worsened. A lumbar magnetic resonance imaging (MRI) showed an anatomical 
anomaly at the L4 vertebra that was diagnosed as spina bifida occulta. Despite physical therapy 
the CI 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 determined this 
disability existed prior to service (EPTS) and was not permanently service aggravated but was 
compensable in accordance with 10 USC Section 1207a. Therefore, the PEB adjudicated the 
low back condition as unfitting, rated 10% with application of 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: “During my Medical Board Seperation [sic], my company 1st Sgt kept putting 
pressure as to when my Medical Board was going to be final. I never appeal my decision due to 
pressure from my unit to leave, so I could be replaced. Here are some orders from my unit at 
the time of discharge. My 1st Sgt name was xxxxxxxxxxx.” 

 

 

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. 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 20030515 

VA (2 Mos. Pre -Separation) – All Effective Date 20030905 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Mechanical Low Back Pain 

5299-5295 

10% 

Low Back Arthrosis 

5292-5295 

10% 

20030626 

.No Additional MEB/PEB Entries. 

Seasonal Allergic Rhinitis w/ 
Intermittent Sinusitis, Migraine 
HA, & Rt Frontal Sinus Cyst 

6513-6522 

30% 

20030626 

Lt Knee Patellofemoral Pain 
Syndrome 

5299-5024 

10% 

20030626 

Residual P/O Lt Shoulder 

5203 

10% 

20030626 

Supraventricular Arrhythmias 

7010 

10% 

20030618 

0% X 3 

20030626 

Combined: 10% 

Combined: 50% 



 


ANALYSIS SUMMARY: 

 

Low Back Condition. The narrative summary (NARSUM) notes that the CI had a long history of 
non-traumatic LBP and when conservative treatment did not help lumbar spine X-rays and 
magnetic resonance imaging (MRI) revealed an anomalous L4 vertebra (spina bifida occulta) 
without evidence of disc herniation or nerve impingement. At the MEB exam, the CI reported 
that his symptoms of back and leg pain started about 6 years earlier without a specific injury 
and had been getting progressively worse since then. Activity such as pulling, pushing, 
repetitive lifting, bending, standing and marching increased his pain. He reported that leaning 
to the right side could relieve the left sided radiation of his back pain down to his legs. There 
were some days that he was pain-free, but mostly the pain waxed and waned. On physical 
exam, range-of-motion (ROM), motor, sensory and reflex exams were normal. At the VA 
Compensation and Pension (C&P) exam, approximately 2 months prior to separation, the CI 
reported constant back pain with exacerbations in intensity with activity such as bending, lifting 
and pulling. There were “no associated features except spasms, numbness, and tingling of 
bilateral legs.” Posture and gait were noted to be normal. On physical exam, ROM, motor, 
sensory and reflexes were normal. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
Board must apply the VASRD rating criteria in effect on the date of the CI’s separation, the 2003 
Veterans’ Administration Schedule for Rating Disabilities (VASRD) coding and rating standards 
for the spine, and the Board did so. The older spine ratings were based on ROM impairment 
which was subject to the rater’s opinion regarding degree of severity, whereas the current 
standards specify rating thresholds in degrees of ROM impairment. The older spine ratings also 
did not have the general spine rating formula provision of including pain (whether or not it 
radiates). The PEB and the VA both rated the mechanical LBP condition analogous to 5295 at 
10%. The evidence in the record is that the CI had LBP with full, but painful ROM, without 
evidence of radiculopathy or systemic problems, and no incapacitating episodes at the time of 
separation. The Board was unable to find a pathway to a higher rating under any applicable 
VASRD 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 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 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 

Mechanical Low Back Pain 

5299-5295 

10% 

COMBINED 

10% 



 

 

 

 


The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120621, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxx, 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 xxxxxxxxxxxxxxxxx, AR20130006167 (PD201201096) 

 

 

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 xxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)