RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

SEPARATION DATE:  20050128 

 
NAME:  XXXXXXXXXXXXXXXX                                                           BRANCH OF SERVICE:  ARMY 
CASE NUMBER:  PD1200363 
BOARD DATE:  20121026 
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered  individual  (CI)  was  an  active  duty  SSGT/E-6  (63M30/Bradley  Fighting  Vehicle  System 
Maintainer),  medically  separated  for  chronic  back  pain  status  post  L4-S1  fusion.    He  did  not 
respond  adequately  to  operative  and  rehabilitative  treatment  and  was  unable  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  L4-S1  transforaminal  lumbar  interbody  fusion  to  the  Physical 
Evaluation  Board  (PEB)  as  medically  unacceptable  IAW  AR  40-501.    No  other  conditions 
appeared on the MEB’s submission.  The PEB adjudicated the chronic back pain  condition as 
unfitting,  rated  20%  with  application  of  the  Veteran’s  Affairs  Schedule  for  Rating  Disabilities 
(VASRD).  Upon the CI’s written appeal, the USAPDA confirmed the findings of the PEB and he 
was then medically separated with a 20% disability rating. 
 
 
CI CONTENTION:  “Lower back injury, spinal fusion” 
 
 
SCOPE OF REVIEW:  The Board wishes to clarify that the scope of its review as defined in the 
Department of Defense Instruction (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  chronic  back  pain  condition  requested  for  consideration  meets  the  criteria 
prescribed  in  DoDI  6040.44  for  Board  purview,  and  is  accordingly  addressed  below.    The 
remaining conditions rated by the VA at separation and listed on the DA Form 294 application 
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: 
 

VA (1 Mo. Pre -Separation) – All Effective Date 20050129 

Service IPEB – Dated 20040909 
Condition 

Code 
5241 

Rating 
20% 

Chronic Back Pain Status 
Post L4-S1 Fusion 

Condition 

Herniated Nucleus Pulposus 
Lumbosacral Spine 
Myofascial Syndrome C-Spine 
Bilateral Keratitis 
Gastroesophageal Reflux 
Tender Scar, L-Spine 
Onychomycosis 

Code 

5237-5243 
5299-5237 
6001-6018 
7339-7346 

7804 

Rating 
40% 
10% 
10% 
10% 
10% 
10% 

Exam 

20050106 
20050106 
20041221 
20050106 
20050106 
20050106 
20050106 

7813-7806 
0% X 2 / Not Service-Connected x 3 

Combined:  60% 

↓No Additional MEB/PEB Entries↓ 

Combined:  20% 

 
 
 
 

Thoracolumbar ROM in 

degrees 

Flexion (90 Normal) 

Ext (0-30) 

R Lat Flex (0-30) 
L Lat Flex 0-30) 
R Rotation (0-30) 
L Rotation (0-30) 
Combined (240⁰) 

Comment 

§4.71a Rating 

35 (35,30,35) 

5 (5, 5, 5) 

20 (20, 20, 20) 
15 (15, 15, 15) 
25 (25, 25, 30) 
30 (25, 30, 30) 

130 

20% 

35 
5 

Not Reported 

Inclinometer 

-- 

20% 

15 
15 
10 
20 
20 
15 
95 

40% 

ANALYSIS SUMMARY:    
 
Lumbar Spine Condition.  After several years of low back pain, the CI had lumbar disc surgery in 
August 2001 for progressive right leg radicular pain.  The outcome was excellent, but re-injury 
from a motor vehicle accident in August 2002 led to significant pain and bilateral sciatica.  After 
lumbar  fusion  performed  in  April  2004,  radicular  symptoms  resolved,  but  he  continued  to 
experience significant pain.  There were three goniometric 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.   
 

MEB ~6 Mo. Pre-Sep 

PT ~3 Mo. Pre-Sep 

VA C&P ~3 Wks. Pre-Sep 

Slow, guarded movement 

+ Painful motion, tenderness 

 
At the narrative summary (NARSUM) examination performed 12 August 2004 (5 months prior 
to separation) and 4 months after surgery, the CI denied radicular symptoms.  The examiner 
stated  that  the  surgery  resulted  in  “good  resolution  of  his  symptoms”  although  he  was  in 
“constant  and  moderate”  pain.    Examination  revealed  no  tenderness  and  no  evidence  of 
sacroiliac joint pain.  The MEB examiner reported that pain and bilateral sciatica were present, 
but  were  much  better  since  surgery.    He  did  not  use  a  back  brace.    Examination  showed  a 
positive  straight  leg  raise  (SLR)  test  bilaterally  and  decreased  sensation  in  both  thighs.    A 
physical  therapy  note  3  months  prior  to  separation  reported  that  the  CI  was  experiencing 
significant pain that interfered with sleep and caused an inability to bend or sit.  Pain severity 
was never less than seven on a 1 to 10 scale.  The CI was riding a bike and lifting light weights 
each  morning  at  the  gym.    At  the  VA  Compensation  and  Pension  (C&P)  exam  performed  3 
weeks  prior  to  separation  (6  January  2005),  the  CI  reported  unremitting  back  pain  that 
prevented  his  ability  to  perform  yard  work  and  was  exacerbated  by  movement,  prolonged 
standing or walking more than 15 minutes.  Pain severity was reported to be 8 out of 10 at rest.  
The pain occurred daily and radiated to both buttocks, but symptoms of  radiculopathy were 
absent.    He  took  a  narcotic  pain  medication  3  times  per  day.    Examination  noted  mild  to 
moderate distress and an antalgic gait due to back pain.  Posture was normal, but spasm wasn’t 
mentioned.    Weakened  movements  against  resistance,  fatigability  with  use  and  lack  of 
endurance  were  reported,  although  repetitive  measurements  were  not  provided.    Muscle 
strength, sensation and deep tendon reflexes (DTR) were normal.  There was no evidence of 
radiculopathy.    10  months  after  separation,  a  VA  clinic  provider  reported  that  the  CI  was  a 
student.  The CI indicated that his pain level was 5 out of 10, and he was only taking over the 
counter pain medication.  He was noted to have a steady gait. 
 
The Board directs attention to its rating recommendation based on the above evidence.  The 
PEB assigned a 20% rating under the 5241 code (spinal fusion) based on flexion of 35 degrees.  
The VA’s 40% rating under a 5237-5243 code (lumbosacral strain, intervertebral disc syndrome) 
was based on lumbar flexion of 15 degrees.  Under the §4.71a spine formula, forward flexion of 
30 degrees or less justifies a 40% rating; and flexion greater than 30 degrees, but not more than 
60 degrees, combined ROM not greater than 120 degrees, or muscle spasm or guarding severe 
enough to result in an abnormal gait or abnormal spinal contour  justifies a 20% rating.  The 
Board agreed that the respective ratings assigned by the PEB and the VA were consistent with 
the available data.  In its deliberation, the Board considered that the two service ROM exams 

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performed 3 months apart were identical, and that the outpatient VA follow-up visit performed 
10 months after separation noted the pain severity had lessened, over the counter medication 
was  being  used  for  pain  control  and  there  was  no  longer  an  antalgic  gait.    Board  members 
agreed  that  the  internal  consistency  of  the  exam  data  and  the  post  separation  evidence 
indicative of an improving condition most accurately depicted the overall clinical picture.  The 
Board also considered whether a rating higher than the PEB’s 20% could be achieved under the 
formula  for  rating  intervertebral  disc  disease  based  on  incapacitating  episodes.    However, 
criteria for the minimum 10% rating under that formula were not present.  The Board further 
deliberated if additional disability was justified for radiculopathy in this case.  Although the CI 
complained  of  intermittent  radiating  pain,  and  one  examiner  noted  a  positive  SLR,  all  other 
examiners  documented  that  no  clinically  significant  radiculopathy  existed.    The  presence  of 
functional  impairment  with  a  direct  impact  on  fitness  is  the  crucial  factor  in  the  Board’s 
decision to recommend any condition for rating as additionally unfitting.  Any lower extremity 
pain  components  in  this  case  have  no  functional  implications,  and  the  Board  therefore 
concludes that additional disability rating was not justified on this basis.  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 lumbar spine 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 chronic back pain 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:   
 

VASRD CODE  RATING 

5241 

COMBINED 

20% 
20% 

Chronic Back Pain Status Post L4-S1 Fusion 

UNFITTING CONDITION 

 
 
The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20120310, w/atchs 
Exhibit B.  Service Treatment Record 
Exhibit C.  Department of Veterans’ Affairs Treatment Record 
 
 
 
 
 
 
 
 
 
 

           XXXXXXXXXXXXXXXX 
           President 
           Physical Disability Board of Review 

   3                                                           PD1200363 
 

 

 

 

 

 

 

 

 

 

SFMR-RB 
 
 
MEMORANDUM FOR Commander, US Army Physical Disability Agency  
(TAPD-ZB /  ), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557 
 
SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXXXXXXXX, AR20120020614 (PD201200363) 
 
 
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 
 
 
 
CF:  
(  ) DoD PDBR 
(  ) DVA 
 
 

     XXXXXXXXXXXXXXXX 
     Deputy Assistant Secretary 
         (Army Review Boards) 

 
 
 

 
 
 

 
 
 

 
 
 

 
 
 

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