RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2021-00015
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070331

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Petroleum Supply Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.   

CI CONTENTION:  “Not all diagnosis were considered…”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20070124	VARD - 20070905	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5237	10%	Degenerative Disk Disease L3-4, L4-5, and L5-S1 with Lumbosacral Strain	5243	10%	20070221	
Obesity	Not Unfitting	No VA Placement	
Acute Anxiety	Not Unfitting	Depressive Disorder	9434	10%	20070307	
Chronic Tension Headaches	Not Unfitting	Tension Headache Disorder	8199-8100	0%	20070221	
Right Ankle Pain	Not Unfitting	Right Ankle Sprains	5271	0%	20070221	
Hypercholesterolemia	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s LBP condition began in November 2001 while participating in Airborne operations when he began feeling sharp pain in his lower back and again reported low back pain in 2004 without any specific injury or trauma.  Imaging from March 2006 showed minimal degenerative disc bulge at L3-4 with more anterior component.  There was no surgical indication.  

During the 9 August 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported having low back pain.  Physical examination revealed no scoliosis or lordosis.  The CI had a normal gait.  Range of motion (ROM) measurements were not recorded.

The 27 July 2006 MEB NARSUM examination, 8 months prior to separation, noted complaints of constant pain which was 10 on a scale up to 10.  Physical examination showed a normal gait.  ROM measurements for active lumbar flexion was 100 degrees (normal 90) and combined active ROM of 215 degrees (normal 240) after three repetitions of each movement.  There was tenderness and muscle spasms present.  Origin of limitation was pain. 

At the 21 February 2007 Compensation and Pension (C&P) examination, 1 month before separation, the CI reported daily stiffness and pain.   Physical examination showed tenderness.   ROM measurements showed active flexion of 76 degrees (normal 90) and combined active ROM of 220 degrees (normal 240).  There was pain and stiffness with repetitive motions.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, analogously coded 5299-5237 (lumbar spine strain), citing tenderness, muscle spasm, and no deficit in gait.  The VA also rated the LBP condition 10%, coded 5243 (intervertebral disc syndrome), based on the C&P examination, citing painful limited motion. 

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the NARSUM and VA examinations.    The panel also noted a 10% rating would also be equally justified for the presence of painful motion, tenderness, and spasm, as reported on the NARSUM and VA examination.  Although there was muscle spasm, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.

After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the LBP condition.  

Contended PEB Conditions:  Chronic Tension Headaches; Right Ankle Pain; and Hypercholesterolemia.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.  

Contended PEB Conditions:  Obesity.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The obesity condition was not profiled and was not implicated in the commander’s statement; however it did fail retention standards (medically unacceptable).   There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  The panel noted that IAW DoDI 1332.38, enclosure 5, obesity is a condition not constituting a physical disability.  Therefore the contended condition is not ratable.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the obesity condition, so no additional disability rating is recommended.  

Contended PEB Conditions: Acute Anxiety.  The panel’s main charge is to assess the fairness of the PEB’s determination that mental health condition was not unfitting.  The mental health condition was profiled after the MEB was initiated for the unfitting low back pain, however, it was not implicated in the commander’s statement, and did not fail retention standards.  The treating psychiatrist indicated significant improvement in symptoms with medication.  At the time of separation, the CI’s symptoms were stable and he reportedly was doing well.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the mental health condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the low back pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended obesity; acute anxiety; chronic tension headaches; right ankle pain; and hypercholesterolemia conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20210121, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

	

AR20210017069, XXXXXXXXXX 

Dear XXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,