RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201170 SEPARATION DATE: 20020215 

BOARD DATE: 20130307 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (92A/Subsistence Specialist), medically 
separated for chronic low back pain (LBP) status post (s/p) fusion for spondylolisthesis. The CI 
sought care for back pain in August 1999 after injuring her back while doing a physical fitness 
test. In April 2000, she underwent an anterior release and posterior spinal fusion for 
spondylolisthesis. Post-operatively the course was complicated by wound dehiscence and deep 
infection requiring two I&D’s. In January 2001 she underwent removal of the hardware. Her 
back condition could not be adequately rehabilitated to meet the physical requirements of her 
Military Occupational Specialty (MOS). Her profile allowed for an alternate physical fitness test. 
She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). 
Mitral valve prolapse (MVP) which was asymptomatic, identified in the rating chart below, was 
also identified and forwarded by the MEB. The Physical Evaluation Board (PEB) adjudicated the 
low back condition as unfitting, rated 10%, with application of the Department of Defense 
Instruction (DoDI) 1332.39. The remaining condition was determined to be not unfitting and 
therefore not rated. The CI made no appeals, and was medically separated with a 10% 
disability rating. 

 

 

CI CONTENTION: The CI elaborated no specific contention in her application. 

 

 

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 20011025 

VA (9 Mos. Post-Separation) – All Effective Date 20020216 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Low Back Pain 

5299-5295 

10% 

Post Decompression and Spinal 
Fusion for Spondyolisthesis L5-S1 

5295 

20%* 

20021126 

Mitral Valve Prolapse 

Not Unfitting 

No VA Entry 

.No Additional MEB/PEB Entries. 

0% X 1 / Not Service-Connected x 0 

20021126 

Combined: 10% 

Combined: 20% 



*Increased to 100% on 20080709 and then reduced to 40% effective 20081001. 

The 0% rating increased to 10% on 20101108. 

 

 

 

 


ANALYSIS SUMMARY: 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. This role and authority is granted by Congress to the 
Department of Veterans Affairs (DVA). The Board’s authority as defined in DoDI 6044.40 
resides in evaluating the fairness of DES fitness determinations and rating decisions for 
disability at the time of separation. 

 

Chronic Low Back Pain, Status Post Fusion for Spondylothesis. The 2002 Veteran Administration 
Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine, which were 
in effect at the time of separation, were changed to the current §4.71a rating standards on 
26 September 2003, and were identical to the interim VASRD standards used by the VA in its 
rating decision. The ratings prior to 26 September 2003 were based on a judgment as to 
whether the disability was mild, moderate or severe. The current standards are grounded in 
range-of-motion (ROM) measurements. IAW DoDI 6040.44, this Board must consider the 
appropriate rating for the CI’s back condition at separation based on the VASRD standards in 
effect at the time of separation. 

 

ROM in evidence is provided in the following table: 

 

Thoracolumbar ROM 

MEB ~6 Mo. Pre-Sep 

VA C&P ~7 Mo. Post-Sep 

Flexion) 

45 

60 

Ext 

20 

15 

R Lat Flex 

25 

20 

L Lat Flex 

25 

20 

R Rotation 

- 

30 

L Rotation 

- 

30 

§4.71a Rating 

20% 

20% 



 

At the orthopedic surgery MEB exam in August 2001, 6 months prior to separation, the CI 
described the intensity of her back pain as 3/10, whereas her pain was 10/10 before surgery. 
She reported no radicular pain, whereas she experienced 10/10 radicular pain before surgery. 
She reported lower back discomfort when riding in a vehicle, cold weather, and changes in the 
weather. She was able to walk without limitation. When she was in a forward flexed position, 
she placed her hands on her thighs in order to return to a standing position. The orthopedic 
surgeon noted a well-healed incision with mild tenderness. Her lower extremity strength was 
5 out of 5 (normal). Her hamstring muscles were mildly tight with full extension in a sitting 
position; hip ROM was normal. Deep tendon reflexes (DTR) were 2+ (normal) at the knees and 
ankles. Her gait was normal and non-painful. X-rays of the lumbar spine (June 2001) showed 
posterior spinal fusion from L4 through S2; the original Grade 5 spondylolisthesis was reduced 
to Grade 4 per the official radiology report, although the orthopedist stated it was reduced to 
Grade 3. The alignment of the lumbar spine was normal and there was no significant bony 
abnormality. At the VA Compensation and Pension (C&P) exam in November 2002, 9 months 
after separation, the CI reported that the LBP was aggravated by prolonged standing or sitting, 
bending, or lifting. Bending or lifting also produced stiffness or spasm in her leg muscles. When 
standing for a prolonged time (she was employed as a cashier), she could temporarily alleviate 
the pain by lifting a leg and resting it on the counter. She took ibuprofen for pain as needed. 
She had no history of sudden episodes of instability, weakness, incoordination, or easy 
fatigability. The examiner noted a normal gait and marked tenderness over the lumbar spine 
without paravertebral muscle spasm. Lower extremity muscle strength was 5+ (normal). There 
were no sensory deficits. Straight leg raise (SLR) testing was limited to 45 degrees bilaterally 
with marked tightness of the hamstring muscles. Knee reflexes were normal. The right ankle 
reflex was normal and the left ankle reflex was absent. Plantar reflexes were normal. The 
examiner noted pain at the extremes of ROM. X-rays of the lumbar spine, on the same date, 


showed fusion of the L4/5 vertebral bodies and hardware and alignment of the vertebral 
bodies. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB and VA both applied code 5295 IAW 2002 VASRD. The PEB’s 10% rating was based on 
“characteristic pain on motion.” The VA assigned a 20% rating for “muscle spasm on extreme 
forward bending and loss of lateral spine motion, unilateral, in a standing position.” The Board 
agreed that a 20% rating was supported under 5295 by the documentation of persistent loss of 
lateral spine movement in a standing position; or under the 5292 code (limitation of lumbar 
motion) for “moderate” limitation of motion. The Board further agreed that limitation of 
motion in evidence did not justify a 40% rating under the 5292 or 5295 codes, and concluded 
that other 40% criteria under 5293 (intervertebral disc syndrome) and 5295 were also not 
present. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 
(reasonable doubt), the Board recommends a disability rating of 20% for the chronic LBP 
condition, coded 5292. 

 

 

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 was operant in this case and the condition was adjudicated 
independently of that instruction by the Board. In the matter of the chronic LBP s/p fusion 
condition the Board unanimously recommends a disability rating of 20%, coded 5292 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 her prior medical separation: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic Low Back Pain Status-Post Fusion 

5292 

20% 

RATING 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120206, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for xxxxxxxxxxxxxxxxxxxxx, AR20130007620 (PD201201170) 

 

 

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 xxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)