RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 
NAME:  XXXXXXXXXXXXXXXX                                                            BRANCH OF SERVICE:  ARMY  
CASE NUMBER:  PD1200817                                                              SEPARATION DATE:  20020507 
BOARD DATE:  20130118 
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered  individual  (CI)  was  an  active  duty  PFC/E-3  (92G/Food  Service  Specialist)  medically 
separated for  a  lumbar spine  condition.    She developed  a  worsening  of  chronic  back  pain  in 
2000 and was diagnosed with mechanical back pain without surgical indications.  The condition 
could  not  be  adequately  rehabilitated  to  meet  the  physical  requirements  of  her  Military 
Occupational  Specialty  or  satisfy  physical  fitness  standards.    She  was  consequently  issued  a 
permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The back condition 
was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501; and, no other conditions 
were submitted by the MEB.  The PEB adjudicated the lumbar spine condition as unfitting, rated 
10%, citing criteria of the Veterans Administration Schedule for Rating Disabilities (VASRD), but 
also referencing Department of Defense Instruction (DoDI) 1332.39 and Army Regulation (AR) 
635-40.  The CI made no appeals, and was medically separated with a 10% disability rating. 
 
 
CI CONTENTION:  “Physical Therapist states neck, arm, legs also related to military, so did Dr. 
due to lifting and strain.  Have days unable to get up, but have 2 young kids, 1 with disabilities.”  
 
 
SCOPE OF REVIEW:  The Board wishes to clarify that the scope of its review as defined in DoDI 
6040.44  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  conditions 
“identified but not determined to be unfitting by the PEB.”  The rating for the unfitting lumbar 
spine condition is addressed below.  The requested cervical and extremity conditions were not 
identified and adjudicated by the PEB, and are thus not within the Board’s purview.  These or 
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:  
 

Code 
5299-5295 

Rating 
10% 

Service PEB – Dated 20020313 
Condition 
Chronic Mechanical Low Back Pain 
No Additional MEB/PEB Entries 
Combined:  10% 

 
 
ANALYSIS SUMMARY:  
 

VA (~1 Mo. Pre-Separation) – Effective 20020508 
Rating 
Condition 
Low Back Strain 
10% 
No Additional VA Ratings or Service Connected Conditions 
Combined:  10% 

Code 
5295 

Exam 
20020415 

in  evidence. 

Lumbar Spine Condition.  The CI had a history of intermittent back pain and a prior to service 
history  of  scoliosis,  which  became  more  severe  and  constant  after  a  vaginal  delivery  in 
September 2000.  X-rays were normal except for 10 degrees of dextroscoliosis (mild), and she 
was managed with physical therapy and temporary profiles.  Some outpatient notes document 
radiation  of  pain  down  both  legs,  but  no  diagnosed  radiculopathy  or  abnormal  neurological 
findings  are 
  An  orthopedic  consultant  (6  months  prior  to  separation) 
recommended continued conservative management and MEB referral.  That entry documented 
a “slow gait,” but anatomically normal range-of-motion (ROM) and normal neurologic testing.  
The  narrative  summary  (NARSUM)  noted  constant  pain,  without  mention  of  radiation  or 
neurologic symptoms, imposing restrictions on running and heavy lifting.  The NARSUM cited 
the  above  findings  of  the  orthopedic  consultant,  and  documented  prior  goniometric  ROM 
measurements of flexion to 90 degrees (normal) and combined ROM of 220 degrees (normal 
240 degrees) with pain.  The VA Compensation and Pension exam (3 weeks prior to separation) 
noted “8/10 constant pain, aggravated with normal daily activities.”  No radiation or neurologic 
symptoms were noted.  The VA physical exam noted a normal gait with no comment on spasm 
or tenderness.  Neurologic testing was normal, although the examiner commented, “The joints 
below  were  weaker  throughout  range  of  motion  when  resistance  was  applied.”    The  ROM 
measurements recorded were flexion of 90 degrees and combined ROM of 240 degrees with 
pain increased by repetition. 
 
The Board directs attention to its rating recommendation based on the above evidence.  The 
2002 VASRD coding and rating standards for the spine, which must be applied to the Board’s 
recommendation IAW DoDI 6040.44, differ significantly from the current §4.71a general rating 
formula for the spine.  The applicable coding options for this case are excerpted below.  

5292 Spine, limitation of motion of, lumbar 

Severe ................................................................................................................................... 40 
Moderate .............................................................................................................................. 20 
Slight ..................................................................................................................................... 10 

 
 

 

5295 Lumbosacral strain: 

 

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 osteo-arthritic 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 

The PEB’s DA Form 199 cited “characteristic pain on motion” for its 10% rating under 5295, and 
the criteria for the higher ratings under 5295 were not in evidence.  The VA rating decision cited 
the same criterion under the same code yielding the same rating.  Application of VASRD §4.59 
(Painful  motion)  to  achieve  the  minimum  compensable  rating  under  code  5292  can  be 
supported,  but  is  not  advantageous.    The  only  remaining  code  available  in  the  2002  VASRD 
schedule was 5293 (intervertebral disc syndrome), which is clearly not applicable to this case.  
There was no evidence of ratable peripheral nerve impairment in this case which would provide 
for  additional  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 of 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.  As discussed above, the 
PEB referenced DoDI 1332.39 and AR 635-40 in its rating of the lumbar condition, but it was 
adjudicated independently of those directives by the Board.  In the matter of the lumbar spine 
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 
Chronic Mechanical Back Pain 

VASRD CODE  RATING 
5299-5295 
COMBINED 

10% 
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. 
 
 
 
 
 
 
 
 

 

           XXXXXXXXXXXXX, DAF 
           Director 
           Physical Disability Board of Review 

 
 
 

SFMR-RB 
 
 
 
 
MEMORANDUM FOR Commander, US Army Physical Disability Agency  
(TAPD-ZB / XXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557 
 
SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXX, AR20130002537 (PD201200817) 
 
 
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 
 
 
 
 

     XXXXXXXXXXXXXXXX 
     Deputy Assistant Secretary 
         (Army Review Boards)