RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201130 SEPARATION DATE: 20030831 

BOARD DATE: 20130306 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty PV2/E-2 (91W/TRAINEE) medically separated for a 
lumbar spine condition with degenerative disc disease (DDD). The CI’s back pain began in basic 
training with no apparent traumatic event. He reinjured his back when he fell down a flight of 
stairs in advanced individual training (AIT). Despite physical therapy (PT), nonsteroidal anti-
inflammatory drugs (NSAIDs), and epidural steroid injections (ESIs), the back could not be 
adequately rehabilitated 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 back condition, characterized as chronic 
low back pain/DDD, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No 
other conditions were submitted by the MEB. The informal PEB adjudicated low back pain 
(LBP) w/DDD, L5-S1 as unfitting, rated 10% with application of Department of Defense 
Instruction (DoDI) 1332.39 and 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 writes: “Condition has worsen over time.” 

 

 

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 rating for the unfitting back condition is 
addressed below; no additional conditions are within the DoDI 6040.44 defined 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 Army Board for 
Correction of Military Records. The Board acknowledges the CI’s information regarding the 
significant impairment with which his service-connected condition continues to burden him; 
but, must emphasize that the Disability Evaluation System (DES) has neither the role nor the 
authority to compensate members for anticipated future severity or potential complications of 
conditions resulting in medical separation. That role and authority is granted by Congress to 
the Department of Veterans Affairs (DVA), operating under a different set of laws. The Board 
considers DVA evidence proximate 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 to the Board’s recommendations only to the extent that 
it reasonably reflects the disability at the time of separation. 

 

RATING COMPARISON: 

 

Service IPEB – Dated 20030715 

VA—(20 Mos. Post-Separation) 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

LBP W/DDD L5-S1 

5293-5299-5295 

10% 

DDD, L5-S1 

5237 

20% 

20050414 

No Additional MEB/PEB Entries 

Other x 0 

20050414 

Combined: 10% 

Combined: 20% 



Derived from VA Rating Decision (VARD) dated 20050422, which updated original VARD of 20040730 that NSC’d the 
condition as no STRs were initially available and no VA exam took place until 20050414. 


ANALYSIS SUMMARY: 

 

LOW BACK PAIN W/DDD, L5-S1. As noted, the CI developed LBP in basic training. It resolved 
with conservative management and he finished basic. During AIT, he fell and injured his left 
knee and reinjured his back. The knee pain resolved, but the LBP persisted despite 
conservative management. A lumbar spine X-ray on 8 March 2003 was normal. Magnetic 
resonance imaging (MRI) exam performed on 18 March 2003, 5 months prior to separation and 
5 months after accession, showed a disc bulge at L5-S1 with the protruding disc impinging the 
right S1 nerve root. Per the narrative summary (NARSUM), an orthopedic surgeon diagnosed 
him with DDD of L5-S1 when he was evaluated 3 days later. He was placed on limited duty for 3 
months and treated with PT, NSAIDs and ESIs without resolution. It was determined that he 
would be unlikely to successfully resume active military training and service and a MEB was 
recommended. At the MEB examination on 5 June 2003, just under 3 months prior to 
separation, the CI reported back pain and tingling in both legs. The examiner noted normal 
sensory, motor and reflex examinations and a negative provocative test for nerve root 
irritation. Signs of non-organic pain were absent. There was tenderness of the paraspinal 
muscles, but no spasm. The NARSUM was dictated 2 weeks later and referenced the above 
examination, but also documented normal range-of-motion (ROM). The CI reported that his 
LBP prevented walking or standing for prolonged periods of time, but no periods of 
incapacitation were noted. The VA Compensation and Pension (C&P) exam was not performed 
until 20 months after separation. The CI reported a 2 year history of LBP aggravated by activity 
and relieved by rest. He was able to function with medications such as NSAIDs. He reported 36 
days of incapacitation. On examination, his posture and gait were normal. Motion was painful 
at the extremes and reduced in flexion and extension, 15 and 5 degrees, respectively. The CI 
reported radiation of pain to the arms and legs. He noted increased pain with repetitive use. 
There were no signs of intervertebral disc syndrome with chronic permanent nerve root 
involvement. The neurological examination was normal as was a lumbar spine X-ray. Spasm 
was absent and provocative testing for nerve root irritation remained negative. The Board 
considered the two examinations and determined that the MEB and NARSUM examinations 
had the higher probative value as they were much more proximate to separation and the 
NARSUM accomplished by an orthopedic surgeon. The Board noted that both PEB 
examinations and the C&P examination were essentially normal other than tenderness on all 
and the reduced ROM on the C&P examination. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB utilized the spine rules in effect at the time of separation, which the Board is also required 
to use for adjudication. The VA used the current spine rules which were in effect at the time of 
its 2005 adjudication. The PEB rated the spine at 10% utilizing the analogous codes 5293, 
intervertebral disc syndrome, and 5295, lumbosacral strain. The VA used the code 5237, 
lumbosacral strain, but awarded 20% for reduced lumbar flexion of 60 degrees. The Board 
noted that the flexion was actually 75 degrees even though pain began at 60 degrees. 
Regardless, this is rendered moot by the decreased probative value of the examination. The 
Board noted that the examination by the MEB examiners documented a normal neurological 
examination and normal ROM. Spasm was absent and incapacitation was not documented. 
The Board reviewed the available codes for rating the back and none provided a route to a 
higher rating than the 10% adjudicated by the PEB. 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 back condition. 
There were no other conditions within the Board’s scope of review for consideration. 

 

 

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 for rating the back condition was operant in this case and the 
condition was adjudicated independently of that instruction by the Board. In the matter of the 
back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in 
the PEB adjudication. 

 

 

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 

Low Back Pain with Degenerative Disc Disease L5-S1… 

5293 5299 5295 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120613, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 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 xxxxxxxxxxxxxxxxxxxxxxx, AR20130006162 (PD201201130) 

 

 

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)