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AF | PDBR | CY2012 | PD2012-00756
Original file (PD2012-00756.pdf) Auto-classification: Denied
RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

BRANCH OF SERVICE:  ARMY 
SEPARATION DATE:  20020528 

 
NAME:  XXXXXXXXXXXX 
CASE NUMBER:  PD1200756 
BOARD DATE:  20130122   
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered individual (CI) was an active duty, SGT/E‐5, (95B/Military Police), medically separated 
for low back pain (LBP).  The CI sustained his initial injury “on the job” in the summer of 1999 
although the first entry in medical records for treatment is in December 1999.  The LBP could 
not  be  adequately  rehabilitated  despite  conservative  treatment  and  physical  therapy  (PT).  
Surgery was not recommended and the CI did not improve adequately with treatment to meet 
the  physical  requirements  of  his  Military  Occupational  Specialty  (MOS).    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 adjudicated the 
LBP  condition  as  unfitting,  rated  0%.    The  CI  made  no  appeals,  and was  medically  separated 
with a 0% disability rating.   
 
 
CI  CONTENTION:    “My  condition  is  getting  worse  as  I  age;  knees,  back,  ankle  and  my  feet 
condition  aren’t  getting  better.    I  have  received  back  brace,  leg  brace  and  receive  a  letter 
statement  that  I  was  not  eligible  for  clothing  allowance  even  though  my  injuries  are  service 
connected.    It’s  just  frustrating  to  send  letter  after  letter  and  visit  after  visit  to  only  get  the 
same response.”   
 
 
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 knees, ankle and feet 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 PEB – Dated 20011231 
Condition 

Code 

Rating

Low Back Pain 

5299‐5295 

0% 

VA – All Effective Date 20020520
Condition
Mechanical Low Back Pain
Thoracic 
Dextroscoliosis
Cervical Spine …
0% X 4 / Not Service‐Connected x 2
Combined:  10%*

Spine, 

Mild 

Code
5295
5291 
5003

Rating 
0%* 
0% 
10% 

Exam
20020208
20020208 
20020208

↓No Addi(cid:415)onal MEB/PEB Entries↓ 
Combined:  0% 
*Low back, 5295, changed to 5237 at 10% effective 20050706 with other conditions added for combined 60% rating.   
 
 
 
 
 

ANALYSIS SUMMARY:   
 
Low Back Condition.  At the MEB narrative summary (NARSUM) the CI’s history of back injuries 
and treatments was summarized.  The CI had radiographs indicating “likely transitional vertebra 
(non rib‐bearing lumbar shaped vertebral bodies) at the lumbosacral junction,” and magnetic 
resonance  imaging  (MRI)  indicated  disc  bulge  with  annular  tear.    There  was  no  history  of 
incapacitation  and  peripheral  exam  of  the  lower  extremities.    The  CI  was  not  a  surgical 
candidate.  Range‐of‐motion (ROM) exams from the MEB physical (DD Form 2808), 10 months 
prior to separation, was cited as “showed normal alignment of the spine without step‐off or 
deviation.    There  was  no  tenderness.    ROM  was  full  without  pain.    Straight‐leg  raising  was 
negative.”  The MEB orthopedic consult, 8 months prior to separation, documented “flexion of 
0‐80, extension 0‐20, side bending on the right is 0‐15 and left is 0‐15 degrees.  He is able to 
rotate  to  the  right  30  degrees  and  left  20  degrees.    He  is  mildly  tender  to  palpation  on  the 
paraspinal musculature at around L4‐5 region.  He has a negative Faber test as well.”  Prior PT 
ROMs,  the  month  prior,  were  exactly  the  same.    Lumbar  spine  radiographs  showed  “likely 
transitional vertebra” and MRI of lumbar spine showed mild broad based bulge with annular 
tear  at  L4/5  level.    There  were  multiple  entries  in  the  service  treatment  record  (STR)  that 
demonstrated full ROM, absence of neurological findings, absence of spasms, absence of pain 
with motion, and absence of gait disturbance.  The VA Compensation and Pension examination 
information  (3  months  prior  to  separation),  as  extracted  from  the  VA  Rating  Decision  dated 
May 20, 2002, stated “There is a full ROM without pain or restriction in the lumbar spine with 
flexion  to  95  degrees,  extension  to  35  degrees,  bilateral  lateral  flexion  to  40  degrees,  and 
bilateral rotation to 35 degrees.”   
 
The  Board  directs  attention  to  its  rating  recommendation  based  on  the  above  evidence.    In 
accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the Veterans 
Affairs Schedule for Rating Disabilities (VASRD) in effect at the time of separation.  The Board 
notes  that  the  2002  VASRD  standards  for  the  spine,  which  were  in  effect  at  the  time  of 
separation,  were  changed  to  the  current  §4.71a  rating  standards  in  2003.    For  the  reader’s 
convenience, the 2001 rating codes under discussion in this case are excerpted below.   
 

5292 Spine, limitation of motion of, lumbar: 

5295 Lumbosacral strain: 

Severe........................................................ 40 
Moderate...................................................... 20 
Slight........................................................ 10 
Severe;  with  listing  of  whole  spine  to  opposite  side,  positive 
Goldthwaite's  sign,  marked  limitation  of  forward  bending  in 
standing  position,  loss  of  lateral  motion  with  osteoarthritic 
changes, or narrowing or irregularity of joint space, or some of 
the above with abnormal mobility on forced motion............ 40 
With muscle spasm on extreme forward bending, loss of lateral  
spine motion, unilateral, in standing position............... 20 
With characteristic pain on motion........................... 10 
       With slight subjective symptoms only.......................... 0 
5293 Intervertebral disc syndrome: 

Pronounced; with persistent symptoms compatible 
with sciatic neuropathy with characteristic 
pain and demonstrable muscle spasm, absent 
ankle jerk, or other neurological findings appropriate 
to site of diseased disc, little intermittent 
relief ...................................................... 60 
Severe; recurring attacks, with intermittent relief.......... 40 
Moderate; recurring attacks ................................. 20 
Mild..........................................................10 

 
The PEB rated the back condition coded 5299‐5295 at 0%, stating “Low back pain with physical 
exam noting full ROM with pain.”  A review of the records found no exam with painful motion 
documented  prior  to  separation  and  the  NARSUM  noted  ROM  was  full  without  pain.    It  is 
unclear how the PEB citied “with pain.”  The VA rated the CI at 0% under 5295 citing full ROM 

   2                                                           PD1200756 
 

without pain or restrictions.  All Board members agreed that the scarcity of evidence for pain 
on motion and the limitation of motion described in the NARSUM and the STR entries warrant a 
0%  rating  under  code  5295.    The  Board  also  considered  a  rating  under  the  5292  code  for 
limitation of motion; however, the NARSUM (6 months prior to separation) ROM was noted as 
full without pain.  There was no tenderness and straight leg raise was negative.  The Board also 
considered  a  rating  under  the  5293  code  for  intervertebral  disc  syndrome,  as  the  result  of 
magnetic resonance spine imaging findings of disc bulge with annular tear but while the CI had 
degenerative  disc,  there  was  no  radiculopathy  and  there  were  no  incapacitating  episodes  to 
support  a  minimum  rating  under  this  code  in  effect  at  the  time  of  separation.    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 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 
Mechanical Low Back Pain 

VASRD CODE  RATING
5299‐5295 
COMBINED 

0%
0%

 
 
The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20120609, w/atchs 
Exhibit B.  Service Treatment Record 
Exhibit C.  Department of Veterans’ Affairs Treatment Record 
 
 
 
 
 
 
 
 
SFMR‐RB 
 

 
 

 

 

 

           XXXXXXXXXXXXXXXXXXXX, DAF 
           President 
           Physical Disability Board of Review 

 
 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency  

(TAPD‐ZB / XXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA  22202‐3557 

 
 

 

   3                                                           PD1200756 
 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 

XXXXXXXXXXXXXXXX, AR20130001598 (PD201200756) 

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 
 

 

 

 

 

 

 

 

 

 

 

 

 

     XXXXXXXXXXXXXX 

     Deputy Assistant Secretary 
         (Army Review Boards) 

 

 

 
CF:  

(  ) DoD PDBR 

(  ) DVA 

 
 

   4                                                           PD1200756 
 



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