RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

BRANCH OF SERVICE:  ARMY 
SEPARATION DATE:  20030126 

 
NAME:  XXXXXXXXXXXXXX 
CASE NUMBER:  PD1200783 
BOARD DATE:  20130130 
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered  individual  (CI)  was  an  active  duty  SFC/E-4  (13B10/Artillery),  medically  separated  for 
mechanical  low  back  pain  (LBP)  secondary  to  back  strain.    The  CI  initially  injured his  back  in 
1999  while  lifting  weights  when he  dropped the  bar  on  his  chest  and tried to pick  it  up.    In 
February 2001, the CI was seen in acute care for a month complaint of back pain of unknown 
cause.    Despite  physical  therapy,  chiropractic  care,  multiple  courses  of  nonsteroidal  anti-
inflammatory  Drugs,  muscle  relaxants,  and  activity  modification,  the  CI  failed  to  meet  the 
physical  requirements  of  his  Military  Occupational  Specialty  (MOS)  or  satisfy  physical  fitness 
standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board 
(MEB).  The MEB forwarded lumbar spine:  Mechanical LBP to the Physical Evaluation Board 
(PEB) as medically unacceptable IAW AR 40-501.  The MEB also identified left hip:  trochanteric 
bursitis;  right  ankle  pain;  recurrent  pseudofolliculitis  barbae;  and  hearing  loss,  left  ear  as 
medically acceptable conditions.  The PEB adjudicated the mechanical LBP secondary to back 
strain  as  unfitting,  rated  10%,  with  application  of  the  Veterans  Affairs  Schedule  for  Rating 
Disabilities  (VASRD).   The  remaining  conditions were  determined  to  be not unfitting.   The  CI 
made no appeals, and he was medically separated with a 10% disability rating. 
 
 
CI CONTENTION:  “Continue to have pain (low back, shoulder, and ankle), cause weight gain and 
sleep apnea.” 
 
 
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 unfitting low back condition and the 
not unfitting right ankle condition requested for consideration meet the criteria prescribed in 
DoDI 6040.44 for Board purview, and are accordingly addressed below.  The other requested 
conditions (shoulder, weight gain, and sleep apnea) are not within the Board’s purview.  Any 
condition  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:   
 

Hip: 

Rating 
10% 

Trochanteric 

Code 
5299-5292 
5019 
5299-5271 
7899-7806 
6100 

Exam 
STR 
20030123 
20030123 
20030123 
20030123 
20030123 

Code 
5295 
Not Unfitting 
Not Unfitting 
Not Unfitting 
Not Unfitting 

VA (1 day Post-Separation) – All Effective Date 20030127 
Rating 
Condition 
10% 
Mechanical LBP 
10% 
Trochanteric Bursitis Left Hip 
Recurrent Right Ankle Sprains 
0% 
NSC 
Pseudofolliculitis Barbae 
Bilateral Hearing Loss 
NSC 
0% X 1 Other / Not Service-Connected x 2 Others 
Combined:  20%* 

Service IPEB – Dated 20021023 
Condition 
Mechanical Low Back Pain 
Left 
Bursitis 
Residual Right Ankle pain 
Pseudofolliculitis Barbae 
Hearing Loss, Left Ear 
No Additional MEB/PEB Entries 
Combined:  10% 
*No disability rating change through 2011, although 5299-5292 changed to 5237 in 2005. 
 
 
ANALYSIS SUMMARY:  The Board’s authority as defined in DoDI 6040.44, resides in evaluating 
the  fairness  of  Disability  Evaluation  System  fitness  determinations  and  rating  decisions  for 
disability at the time of separation.  The Board utilizes VA evidence proximal 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 only to the 
extent  that  it  reasonably  reflects  the  disability  and  fitness  implications  at  the  time  of 
separation. 
 
Mechanical Low Back Pain Condition.  There were three 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. 
 
Thoracolumbar ROM 
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 (240) 

Comment 

NARSUM ~5 Mo. Pre-Sep 
85⁰ 
20⁰ 
30⁰ (40⁰) 
30⁰ (40⁰) 
30⁰ (35⁰) 
30⁰ (35⁰) 
225⁰ 
Goniometer  not  noted;  able  to  do  10 
toe raises bilaterally without difficulty; 
walks on heels/toes without difficulty; 
“intermittent  numbness  over 
lower 
back/thighs”;  normal 
leg 
raising (SLR) sitting and supine; 0 to 5 
Waddell signs present; motor/sensory 
intact 
 
10% 
10% 

straight 

NARSUM ~3 Mo. Pre-Sep 
90⁰ 
25⁰ 
30⁰ 
30⁰ 
30⁰ (35⁰) 
30⁰ (35⁰) 
235⁰ 
Goniometer  not  noted;  + 
SLR; 
radiation; 
Neurological  exam  normal; 
“chronic  LBP  radiating  to 
left buttock”; tenderness to 
pressure  (TTP)  lumbosacral 
junction; SLR + 
 
10% 
10% 

- 

spasms; 

C&P ~29 Mo. Post-Sep 
90⁰ (102⁰) 
30⁰ 
30⁰ (40⁰) 
30⁰ (40⁰) 
30 (45) 
30⁰ (45⁰) 
240⁰ 
No 
TTP; 
repeated  testing  did  not 
evidence  painful  motion; 
negative  SLR,  sitting  and 
supine;  no  focal  weakness; 
sensory 
intact  knee/ankle 
jerks  +1;  “back  pain  with 
associated spasms” 
 
0% 
10% 

no 

§4.71a Rating 
5295 
5237 
 
Due to chronic LBP complaints the CI had lumbar spine X-rays in both 2001 and 2002 which 
were both normal.  A bone scan done in 2002 was normal.  The initial MEB narrative summary 
(NARSUM) examination was completed by a physician assistant 5 months prior to separation 
indicated nonradicular  LBP;  intermittent  numbness  over  lower  back  and  bilateral thighs  with 
one to  two episodes  per  week;  and daily  LBP  which  increased  with  activities.    The  examiner 
opined that the CI was not a surgical candidate and had achieved maximal medical intervention.  
The NARSUM physical exam findings are summarized in the chart above.  The CI was granted a 
L3 profile with specific restrictions of no running, no jumping, and no rucksack marching.  The 

second  NARSUM  examination  completed  by  a  physician  3  months  prior  to  separation 
documented  chronic  LBP  that  radiated  to  the  left  buttock  and  was  aggravated  by  running, 
heavy lifting, repeated bending, and fitness bike riding for more than 25 minutes.  The examiner 
referred  to  the  DD  Form  2807  and  DD  Form  2808  completed  in  August  2002  by  the  same 
physician, but also stated a focused physical examination was completed on the day of the new 
NARSUM examination.  The ROM measurements noted in the NARSUM were the same as those 
noted  on  the  DD  Form  2808  and  they  are  recorded  in  the  ROM  chart  above.    Neither 
examination  mentions  a  goniometer.    The  commander’s  statement  noted  that  the  CI’s 
condition left him “incapable of enduring the severe stress and physical exertion that he would 
encounter  in  a  combat  environment.”    The  CI  had  a  VA  Compensation  and  Pension  (C&P) 
general exam 3 days prior to separation, however this examination did not include the lumbar 
spine  and  the  CI’s  initial  VA  disability  rating  was  based  on  the  August  2002  NARSUM  ROM 
measurements.  The C&P examination 29 months after separation noted LBP associated with 
spasms; increased pain by lifting anything heavy; and doing sit-ups, standing for long periods, 
and walking for more than 30 minutes caused pain and stiffness.  The physical exam findings 
are summarized in the chart above.  Subsequent lumbar spine X-rays done in 2005 and 2011 
were all normal. 
 
The  2002  VASRD  coding  and  rating  standards  for  the  spine,  were  in  effect  at  the  time  of 
separation,  but  were  modified  on  23  September  2002  to  add  incapacitating  episodes  (5293 
Intervertebral disc syndrome) and were then changed to the current §4.71a rating standards on 
26 September 2003.  The 2002 standards for rating based on ROM impairment were subject to 
the rater’s opinion regarding degree of severity, whereas the current standards specify rating 
thresholds in degrees of ROM impairment.  When older cases have goniometric measurements 
in  evidence,  the  Board  reconciles  (to  the  extent  possible)  its  opinion  regarding  degree  of 
severity  for  the  older  spine  codes  and  ratings  with  the  objective  thresholds  specified  in  the 
current  VASRD  §4.71a  general  rating  formula  for  the  spine.    This  promotes  uniformity  of  its 
recommendations for different cases from the same period and more conformity across dates 
of separation, without sacrificing compliance with the DoDI 6040.44 requirement for rating IAW 
the VASRD in effect at the time of separation.   
 
The Board directs attention to its rating recommendation based on the above evidence.  The 
PEB coded the LBP condition 5295 Lumbosacral strain (with characteristic pain on motion) and 
rated  10%.    The  VA  coded  the  back  condition  5299  analogous  to  5292  Spine,  limitation  of 
motion of, lumbar (slight) and rated 10%.  The initial VA rating was based on the pain-limited 
ROM noted on the August 2002 NARSUM examination.  The VA continued this 10% rating based 
on painful motion after the June 2005 C&P examination.  If today’s VASRD were utilized, these 
same  ratings  would  result.    All  exams  indicated  that  the  CI  experienced  LBP  on  motion  with 
activities.  Neither NARSUM indicated muscle spasms or loss of lateral spine motion.  The C&P 
exam  noted  a  subjective  complaint  of  muscle  spasms;  however,  this  exam  was  29  months 
remote from separation and has a lower probative value.  The Board considered rating under 
5292; however the CI’s condition would not result in a higher rating.  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.   
 
Contended PEB Conditions.  The contended condition adjudicated as not unfitting by the PEB 
was residual right ankle pain.  The Board’s first charge with respect to these conditions is an 
assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for 
countering  fitness  determinations  is  higher  than  the  VASRD  §4.3  (Resolution  of  reasonable 
doubt)  standard  used  for  its  rating  recommendations,  but  remains  adherent  to  the  DoDI 

6040.44 “fair and equitable” standard.  Both NARSUM’s mentioned a bone scan that noted a 
mildly  increased  uptake  in  the  right  ankle.    However,  the  right  ankle  was  asymptomatic  on 
exam and adjudged to meet retention standards.  The right ankle condition was not profiled; 
the CI was granted an L3/H3 profile for LBP and hearing loss with no mention of a right ankle 
restriction.  The commander’s statement only discussed the LBP problem and how it interfered 
with the CI accomplishing his MOS duties.  The residual right ankle pain condition was reviewed 
by the action officer and considered by the Board.  There was no indication from the record 
that  this  condition  significantly  interfered  with  satisfactory  duty  performance.    After  due 
deliberation in consideration of the preponderance of the evidence, the Board concluded that 
there was insufficient cause to recommend a change in the PEB fitness determination for the 
residual  right  ankle  pain  contended  condition;  and,  therefore,  no  additional  disability  ratings 
can be recommended. 
 
 
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.    In  the  matter  of  the 
contended residual right ankle pain condition, the Board unanimously recommends no change 
from  the  PEB  determination  as  not  unfitting.    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 
5295 
COMBINED 

10% 
10% 

 
 
The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20120607, w/atchs 
Exhibit B.  Service Treatment Record 
Exhibit C.  Department of Veterans’ Affairs Treatment Record 
 
 
 
 
 
 
 
 

 

           XXXXXXXXXXXXXXXXXXX, DAF 
           Acting Director 
           Physical Disability Board of Review 

 
 

 
 

 
 

 
 
 

SFMR-RB 
 
 
 
 
MEMORANDUM FOR Commander, US Army Physical Disability Agency  
(TAPD-ZB / XXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557 
 
SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXX, AR20130003031 (PD201200783) 
 
 
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 
 
 

     XXXXXXXXXXXXXXXXX 
     Deputy Assistant Secretary