RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00906
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040628

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Petroleum Supply Specialist, medically separated for “chronic low back pain without neurologic abnormality” with a disability rating of 10%.  The PEB also determined “polycystic kidney disease” existed prior to service (EPTS), was not permanently aggravated, and was not rated.

CI CONTENTION:  Used evidence (polycystic kidney disease and low back strain) supports a higher rating.  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 PEB - 20040513	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	No VA Examination Proximate to Separation in Evidence	
Polycystic Kidney Disease	7533	---%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in the absence of trauma although he did “a lot of bouncing around” during deployment in August 2003. The CI reported his left side (lumbar) felt “tight and sore” in December 2003.  Magnetic resonance imaging on 5 January 2004 showed a normal lumbar spine.  Despite nonsteroidal anti-inflammatory drugs and muscle relaxers, the CI experienced constant pain with muscle spasms.  A CT scan performed to evaluate LBP demonstrated polycystic kidneys.

On 29 January 2004 a medical record, 5 months before separation, documented the CI’s range of motion (ROM) as flexion to approximately one foot from touching his toes (approximately 80-90 degrees, normal 90) and combined ROM was approximately 190 degrees (normal 240); painful motion was not addressed.

During the 25 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported bilateral LBP with an abrupt onset but without trauma.  Physical examination showed tenderness of the lower back paralumbar areas bilaterally and no costovertebral angle tenderness. 

The 25 March 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of back pain that was described as a flank pain, which ached and was constant and deep, and a more typical LBP, which was aggravated by prolonged standing and other positions.  Physical examination showed a smooth and easy gait, bilateral spinal muscle spasms and tenderness.  Spine posture was described as a generalized right rotation with side bending left to the lower thoracic-upper lumbar region.  ROM was flexion to 20 degrees and combined ROM was 105 degrees with painful motion. Gait was smooth and easy.  Neurologic evaluation was unremarkable and a seated straight leg raise (to determine nerve root irritation) was negative bilaterally.  During the 26 March 2004 internal medicine visit the CI complained of constant LBP.  Physical examination documented normal ambulation.  During the 26 April 2004 internal medicine visit, 2 months before separation, the examiner opined the CI’s LBP as “secondary to polycystic kidney disease and mechanical.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing pain, limited motion, tenderness and spasm.  

Members deliberated the scant STR ROM evidence proximate to separation on which to adequately rate the chronic LBP with a high level of certainty.  The CI was able to forward flexion to approximately 70 degrees 5 months prior to separation, while 3 months prior to separation flexion was 20 degrees.  The panel agreed although there was no documented accident or injury during this short period, the MEB NARSUM examination was most thorough and holds the highest probative value, documenting exact ROMs, muscle spasms, tenderness and an abnormal spinal posture.  The panel agreed that a 40% rating, was justified for limitation of flexion not greater than 30 degrees.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 40% for the chronic LBP condition, coded 5299-5237.

Polycystic Kidney Disease.  According to the STR and MEB NARSUM, the CI’s polycystic kidney condition was diagnosed by CT scan, which showed multiple cysts in the kidneys bilaterally, left greater than right in January 2004 after experiencing back pain and high blood pressure.  The hypertension was treated with hydrochlorothiazide, a diuretic, and benazepril, an ACE (angiotensin converting enzyme) inhibitor.  He also was noted to have anemia but was not iron deficient.  Albumin and sugar were negative in the urine at the MEB examination on 25 February 2004.  At a urology examination on 23 March 2004 the CI reported a dull ache of the left flank.  Physical examination revealed a soft abdomen and both kidneys were slightly palpable, but not significantly enlarged or tender.

The 25 March 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of back pain and polycystic kidney disease.  Physical examination showed his abdomen was soft with decreased bowel sounds and mild left upper quadrant tenderness with deep palpation.

During the 12 June 2004 VA ambulatory (outpatient) examination, less than 1 month after separation, the CI’s blood pressure was 152/87 with a repeat of 138/88.  The abdomen was soft, nontender, with good bowel sounds and no organomegaly.  Lisinopril, also an ACE inhibitor was substituted for benazepril.  On 7 October a CT scan revealed bilateral polycystic kidneys, but no other cystic problems in any other organ.  At a nephrology consultation on 11 November 2004 the CI stated he had a strong family history of polycystic kidney disease.  Physical examination showed a blood pressure of 138/80.  His abdomen was soft with bowel sounds in all four quadrants.  There was no tenderness, organomegaly or masses.  The examiner’s diagnosis was autosomal dominant polycystic kidney disease.  The genetics, disease progression statistics, complications, associated disease, and treatment were reviewed.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the polycystic kidney condition as EPTS, coded 7533 (cystic diseases of the kidneys (polycystic disease)), citing “compelling evidence to support a finding that the condition was EPTS and not permanently service aggravated (PSA) beyond the natural progression by such service.”  

As noted, the PEB determined the polycystic kidney condition was EPTS based on a strong family history, although the CI was asymptomatic prior to entering military service.  The panel found no evidence to indicate this was incorrect.  The panel next considered whether or not there was evidence of PSA.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  During the CI’s deployment he encountered “a lot of bouncing around” in vehicles that presented as back pain, which an examiner indicated was secondary to the polycystic kidney disease.  Therefore, while it is uncertain whether vehicular vibration caused damage to the kidneys or induced cyst hemorrhage, nevertheless, as a result of the polycystic kidney disease, the back pain became manifest and recalcitrant to treatment.  Therefore, panel members believe the polycystic kidney disease was aggravated by service despite kidney function remaining normal. It was the polycystic kidneys, which had been attributed to traction of the renal pedicle, distension of the capsule, and compression of nearby structures, that may have been the etiology of the chronic lower back pain as is documented by an Advanced Chronic Kidney Disease manuscript at (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4144785/).

Members then determined that the condition was unfitting.  Polycystic kidney disease is rated under code 7533 which is then referred to renal dysfunction.  A 30% rating under renal dysfunction includes, “albumin constant or recurring with hyaline and granular casts or red blood cells [kidney disease]; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101 [hypertensive vascular disease or hypertension and isolated systolic hypertension].  A 0% rating requires albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101.  The panel agreed a 0% rating, but no higher, was justified since there was no albumin, casts or compensable hypertension.  The panel determined the CI did not meet the 10% rating requirements for code 7101 which requires diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the polycystic kidney disease condition, coded 7533.

BOARD FINDINGS:  In the matter of the chronic LBP condition, the panel unanimously recommends a disability rating of 40%, coded 5299-5237 IAW VASRD §4.71a.   In the matter of the polycystic kidney disease condition, the panel unanimously recommends a disability rating of 0%, coded 7533 IAW VASRD §4.115b.  There are no other conditions within the panel’s scope of review for consideration.  The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5299-5237	40%	
Polycystic Kidney Disease	7533	0%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170018430, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure