RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

BRANCH OF SERVICE:  ARMY 
SEPARATION DATE:  20030805 

 
NAME:  XXXXXXXXXXXXXX 
CASE NUMBER:  PD1201090 
BOARD DATE:  20130130 
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered  individual  (CI)  was  an  active  duty  SPC/E-4  (31R/Telecommunication  Operator), 
medically separated for chronic low back pain (LBP).  The CI sustained a low back injury while 
lifting  a  heavy  cable  reel  in  June  of  1999  and  extensive  non-surgical  treatment  provided  no 
relief of his symptoms.  He did not improve adequately to meet the physical requirements of his 
Military  Occupational  Specialty.    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  chronic  LBP  condition  as 
unfitting, rated 10%,  with application of the Veteran’s  Affairs Schedule for Rating Disabilities 
(VASRD).  The CI made no appeals and he was medically separated with a 10% disability rating. 
 
 
CI CONTENTION:  The CI elaborated no specific contention in his 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 rating for 
the  unfitting  chronic  LBP  condition  will  be  reviewed.    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 20030806 

Service IPEB – Dated 20030429 
Condition 

Code 

Rating 

*Combined rating eventually increased to 80% effective 20100728 with no changes to the low back or bilateral radiculopathy 
ratings 
 
 
ANALYSIS  SUMMARY:    The  Board’s  role  is  confined  to  the  review  of  medical  records  and  all 
evidence  at  hand  to  assess  the  fairness  of  PEB  rating  determinations,  compared  to  VASRD 
standards, based on severity at the time of separation.  The Board notes the current VA ratings 
for all of his service-connected conditions, but must emphasize that its recommendations are 

Chronic Low Back Pain 

5299-5295 

10% 

↓No Additional MEB/PEB Entries↓ 

Combined:  10% 

Condition 

Low Back Pain 
Left Radiculopathy 
Right Radiculopathy 
Obstructive Sleep Apnea 
Bilateral Ankle Sprain 

Code 
5292 

8599-8520 
8599-8520 

6847 

5271-5010 

Rating 
10% 
10% 
10% 
30% 
10% 

Exam 

20030703 
20030703 
20030703 
20030703 
20030703 

0% x5 

Combined:  60*% 

premised on severity at the time of separation.  The VA ratings that it considers in that regard 
are those rendered most proximate to separation.  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.  That role and authority is 
granted by Congress to the Department of Veterans Affairs. 
 
Chronic Low Back Pain Condition.  The narrative summary (NARSUM) prepared 8 months prior 
to  separation,  noted  the  CI  had  a  3-year  history  of  intermittent  LBP  that  got  progressively 
worse.    The  onset  of  symptoms  was  in  June  1999  when  the  CI  suffered  a  lifting  injury  and 
experienced immediate pain in his back.  The pain had both a constant dull, burning component 
and a sharp sensation with certain activities.  The severity was described as seven out of ten 
and exacerbating factors included include running, jumping, lifting, many physical activities, and 
driving more than 45 minutes.  Alleviating factors included rest, frequent changing of position, 
and taking medication.  Most of the CI's pain originated from the midsection of his low back and 
radiated pain and paresthesias distally to the low back and into the legs, left greater than right.  
The pain was worse in the morning.  The CI denied sensation loss, weakness, bowel or bladder 
incontinence, night sweats, fevers, or unexplained weight loss.  Medications, which the CI had 
tried,  included  non-steroidal  anti-inflammatories,  muscle  relaxers,  and  narcotic  medications 
resulted  in  only  incomplete  relief  of  symptoms.    A  trial  of  physical  therapy  (PT)  included 
transcutaneous  electrical  nerve  stimulation  (TENS),  ultrasound,  lumbar  traction,  electrical 
stimulation, manipulation, lumbar stabilization, strengthening and stretching exercises; all with 
no relief of symptoms.  Significant physical exam findings are summarized in the chart below.  
Radiographic data consisted of magnetic resonance imaging (MRI) of the lumbosacral spine and 
was normal.  Plain film X-rays of the SI joints revealed osteoarthritis, sacralization of L5, and 
focal  sclerosis  on  both  sides  of  SI  joint.    The  CI  was  treated  on  an  outpatient  basis.    On 
subsequent follow-up examinations, there was no change from his previous examination except 
now his referred pain was worse to his buttocks, coccyx, and inner leg, left greater than right.  It 
was the commander's recommendation that this soldier was not worldwide deployable.  It was 
unlikely that the CI will improve in pain level and function to the point where he would reach a 
level  consistent  with  active  duty  service.    Prognosis  for  civilian  employment  was  fair.    The 
diagnosis  was  chronic  LBP  and  sacroiliac  (SI)  joint  arthritis,  both  medically  unacceptable  in 
accordance with Army Regulation 40-501.  The recommendation was that the CI was unable to 
satisfactorily  perform  the  duties  of  a  member  of  his  rank  and  station;  therefore,  it  was 
recommended  that  he  be  found  unfit  for  retention  on  active  duty.    At  the  MEB  exam 
accomplished  4  months  prior  to  separation,  the  CI  reported  a  problem  caused  by  his  back 
injury.  “My back cause (sic) me to have tingling & numbness in my legs.  My back problem is 
cause by arthritis and my shoulder blade be (sic) hurting because of my back pain.”  The MEB 
physical exam noted no specific entries related to the CI’s LBP. 
 
The VA Compensation and Pension (C&P) exam accomplished a month prior to separation, was 
consistent with the above history and physical examination with the following additions.  He 
complained of daily constant pain located on the left side of his lower back that radiated down 
his left buttock in a radicular fashion down to his left knee.  He also had right sided radicular 
pain less frequently.  The CI reported he always had to lift up his left leg in order to bend over 
to pick up something off the floor.  He could not bend over to tie his shoes.  He could not lean 
to his left side.  He was unable to lie on his back for more than a few minutes.  Prolonged sitting 
bothered him and he could not travel long distances in a car.  The CI had previously enjoyed all 
sports but no longer did because of his back condition.  He exercised two to three times per 
week on a stationary bicycle and did some weight training.  Current medication was Motrin as 
needed.  Significant physical exam findings are summarized in the chart below.  The diagnosis 
was  mechanical  LBP  with  radiculopathy  and  bilateral  SI  joint  arthritis.    The  functional 

assessment was mild decrease in range of motion, pain with weight-bearing activities, and pain 
on range-of-motion (ROM). 
 
 
 
 

Low Back Physical 

Exam Findings 

NARSUM 8 Mos. Pre-Sep 

VA C&P exam 1Mo. Pre-Sep 

Comments 

Pos. tenderness over SI joint, right 

greater than left, 

Negative Straight leg raise 

Faber test with pain in SI joint 

bilaterally 

DTRs - normal bilaterally 

Sensation - normal bilaterally 

 

§4.71a Rating  

(1 July 2002 Edition) 

10%* 

Normal posture and gait 

No kyphosis, lordosis, or scoliosis 

Normal - Strength, DTRs and sensory exam 

able to reach his fingertips to within five inches of the 

floor on forward flexion 
Negative Straight leg raise 

No paraspinal muscle spasms  

Pos. tender to palpation over left SI joint 

No tenderness to palpation over lumbar spine 

10%* 

*IAW VASRD code 5295 or 5292 with adequate evidence of painful motion IAW §4.59 
 
The Board directs attention to its rating recommendation based on the above evidence.  The 
PEB adjudicated the CI’s chronic LBP as 10% disabling, based on painful motion, and applied the 
analogous VASRD code of 5299-5295, lumbosacral strain.  It also cited a normal MRI, a non-
focal neurological examination, and plain film radiographs showed L5 sacralization and SI joint 
osteoarthritis.  This coding and rating scheme met VASRD principle §4.66, SI joint, which states, 
“The  lumbosacral  and  SI  joints  should  be  considered  as  one  anatomical  segment  for  rating 
purposes.”  The VA applied VASRD code 5292, limitation of lumbar spine motion, and rated it 
10% citing slightly limited motion of the lumbar spine.  In the 2002 VASRD in effect at the time 
of separation, VASRD code 5295, (Lumbosacral strain), was rated with considerations of limited 
motion,  radiographic findings,  muscle  spasm  and  pain;  while  VASRD  code  5292,  limitation of 
lumbar  spine  motion,  was  subjectively  rated  as  slight,  moderate  or  severe.    The  evidence 
present  for  review  would  support  a  “slight”  limitation  in  motion  and  a  corresponding  10% 
rating if VASRD code 5292 were to be applied.  At the time of separation, the CI only had X-ray 
findings  consistent  with  the  40%  rating  with  VASRD  code  5295,  therefore,  the  deliberations 
settled on a 20% versus 10% rating discussion.  The 20% rating criteria required muscle spasm 
on  extreme  forward  bending  and  unilateral  loss  of  lateral  spine  motion  in  standing  position.  
The CI complained of having a component of the 20% rating, inability to lean to the left side, 
however, on examination he had no muscle spasm and there was no documented loss of lateral 
motion.  The examiner’s functional assessment was that there was a mild decrease in the ROM 
with  pain,  which  is  consistent  with  the  10%  rating.    The  constellation  of,  X-ray  findings 
(consistent  with  40%  rating),  subjective  loss  of  the  ability  to  lean  left  (consistent  with  20% 
rating) and documented painful motion (consistent with 10% rating) is overall most consistent 
with a 20% disability rating.  Board precedent is that a functional impairment tied to fitness is 
required to support a recommendation for addition of a peripheral nerve rating at separation.  
There  were  no  sensory  or  motor  changes  evident  in  the  documentation  present  for  review.  
Since  no  evidence  of  functional  impairment  exists  in  this  case,  the  Board  cannot  support  a 
recommendation  for  additional  rating  based  on  peripheral  nerve  impairment.    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. 
 
 

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  LBP  condition,  the  Board  unanimously 
recommends a disability rating of 20%, coded 5299-5295 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 his prior medical separation: 
 

VASRD CODE  RATING 
5299-5295 
COMBINED 

20% 
20% 

           XXXXXXXXXXXXXXXX, DAF 
           Acting Director 
           Physical Disability Board of Review 

Chronic Low Back Pain Condition 

UNFITTING CONDITION 

 
 
The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20120621, w/atchs 
Exhibit B.  Service Treatment Record 
Exhibit C.  Department of Veterans’ Affairs Treatment Record 
 
 
 
 
 
 
 
 

 

 
 
 

SFMR-RB 
 
 
 
 
MEMORANDUM FOR Commander, US Army Physical Disability Agency  
(TAPD-ZB / XXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557 
 
 
SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation  
for XXXXXXXXXXXXX, AR20130003102 (PD201201090) 
 
 
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 
 
 
 

     XXXXXXXXXXXXXXXXX 
     Deputy Assistant Secretary 
         (Army Review Boards)