Search Decisions

Decision Text

AF | PDBR | CY2013 | PD-2013-02787
Original file (PD-2013-02787.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-02787
BRANCH OF SERVICE: Army  BOARD DATE: 20150625
SEPARATION DATE: 20060803


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Combat Engineer) medically separated for a back condition. The condition could not be adequately rehabilitated 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 an Medical Evaluation Board (MEB). Low back pain, secondary to interbody fusion, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB (IPEB) adjudicated chronic back pain as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) . The CI made no appeals, and was medically separated.


CI CONTENTION: The CI elaborated no specific contention in his application.


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any condition outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


 RATING COMPARISON :
Service IPEB – Dated 20060612
 VA* - (~1 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Back Pain… 5241 10% S/P Fusion L4-L5… 5241 20% 20060918
Other MEB/PEB Conditions x 0 (Not In Scope)
 Other x 2
RATING: 10%
 RATING: 20%
*Derived from VA Rating Decision (VARD) dated 20060918 (most proxima te to date of separation [DOS] )



ANALYSIS SUMMARY:

Chronic Back Pain. The CI had a history of longstanding low back pain (LBP) for which he was seen sporadically until early 2005. An MRI (not in evidence) showed a herniated disc at L4-5 and degenerative disc disease. He underwent L4-5 fusion on 18 March 2005. Despite rehabilitation after surgery, his LBP persisted and precluded full duty. At the MEB Report of Medical Examination (DD Form 2808) dated 31 March 2006, 4 months before separation, the CI reported LBP since 1998. The examiner recorded limited and painful motion, but a normal gait and neurological examination. At the MEB narrative summary (NARSUM) examination dated 11 May 2006, 3 months before separation, the CI reported constant LBP aggravated by activity and sitting. Spasm was present. The neurological examination was normal. No comment was made on gait, posture, or incapacitation.

At the VA Compensation and Pension (C&P) examination dated 5 July 2006, a month before separation, the CI reported difficulty with prolonged sitting and ambulation. Putting on his shoes and socks was difficult at times. He did not use a support and denied incapacitation. On examination, the posture, gait, and neurological evaluation were normal. The scar was well healed. The range-of-motion (ROM) was painful and limited (below), but did not decrease further with repetition.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)
 PT ~4 Mo. Pre-Sep VA C&P ~ 1 Mo. Pre-Sep
Flexion (90 Normal)
 55 60
Combined (240)
 190 210
Comment
 M otion limited by p ain Painful motion
§4.71a Rating
 20% 20%

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the back at 10% and the VA 20%. Both used the back code 5241 (spinal fusion). The ROM at both the PT and C&P examinations supports a 20% rating. The Board found no route to a higher rating at separation than 20%. The evidence does not support the presence of an unfitting radiculopathy at separation. 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 back 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 back condition, the Board unanimously recommends a disability rating of 20%, coded 5241 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:

CONDITION
 VASRD CODE RATING
Chronic Back Pain status post L4-5 Fusion 5241 20%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131218, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record




XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review





 SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX , AR20150012829 (PD201302787)
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                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

Similar Decisions

  • AF | PDBR | CY2014 | PD-2014-00914

    Original file (PD-2014-00914.rtf) Auto-classification: Denied

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. A pproximately 9 months prior to separation a physical therapist performed ROMs for the MEB exam , which are summarized below. Accordingly, the Board recommended no re-characterization or modification of your...

  • AF | PDBR | CY2014 | PD-2014-00351

    Original file (PD-2014-00351.rtf) Auto-classification: Denied

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVASRD standards to the unfitting medical condition at the time of separation. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. The “General Rating Formula for Diseases and Injuries of the Spine...

  • AF | PDBR | CY2013 | PD-2013-01347

    Original file (PD-2013-01347.rtf) Auto-classification: Approved

    The Informal PEB found the“chronic back pain, status post lumbar fusion” unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). Post-Separation)ConditionCodeRatingConditionCodeRatingExam Chronic Back Pain, Status Post Lumbar Fusion524110%Herniated Nucleus Pulposus (HNP)524310%20040709Bladder Dysfunction, related to HNP5243-754210%20040709Other MEB/PEB Conditions x 0 (Not in Scope)Other x 3 RATING: 10%RATING: 20% *Derived from VA...

  • AF | PDBR | CY2014 | PD-2014-00566

    Original file (PD-2014-00566.rtf) Auto-classification: Denied

    The Informal PEBadjudicated “chronic back pain”as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).The remaining condition was determined to be not unfitting.The CI made no appeals and was medically separated. It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. ...

  • AF | PDBR | CY2013 | PD2013 00160

    Original file (PD2013 00160.rtf) Auto-classification: Denied

    RECORD OF PROCEEDINGSPHYSICAL DISABILITY BOARD OF REVIEWNAME: xxxxxxxxxxxxxxxxxxxx CASE: PD1300160 BRANCH OF SERVICE: AIR FORCE BOARD DATE: 20131105 The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting. I have carefully reviewed the evidence of record and the recommendation of the Board.

  • AF | PDBR | CY2011 | PD2011-00275

    Original file (PD2011-00275.docx) Auto-classification: Approved

    (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. Chronic Low Back Pain with Fusion L4 to S1 Condition . RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior...

  • AF | PDBR | CY2014 | PD-2014-00501

    Original file (PD-2014-00501.rtf) Auto-classification: Denied

    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 Board for Correction of Military Records. During the VA Compensation and Pension exam (performed 3months after separation), the CI reported a second fusion(a month after separation) secondary to persistent severe LBP with recurrence of leg symptoms. After due deliberation in consideration of the preponderance of the...

  • AF | PDBR | CY2013 | PD-2013-01913

    Original file (PD-2013-01913.rtf) Auto-classification: Approved

    The VARD stated that the 40% rating of the back condition was based on findings in the “service medical records which shows incapacitating episodes between 4 and 6 weeks during the past 12 months (sic).” The Board reviewed the evidence proximate to separation-the MEB and PT ROM for the MEB exams and prior to separation and after separation C&P exams. The CI reported LLE pain and at the MEB exam decreased sensation of the lateral leg and foot was noted. Providing a correction to the...

  • AF | PDBR | CY2014 | PD-2014-00570

    Original file (PD-2014-00570.rtf) Auto-classification: Approved

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. Providing orders...

  • AF | PDBR | CY2013 | PD-2013-01781

    Original file (PD-2013-01781.rtf) Auto-classification: Approved

    RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation: Physical Disability Board of Review 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.