RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXX.	CASE:  PD-2021-00077
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081225

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “chronic low back pain…” with a disability rating of 20%.   

CI CONTENTION:  Review all conditions.  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 - 20080916	VARD - 20090709	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5237	20%	Lumbosacral Strain	5237	0%	N/A	
History of Right Nephrolithiasis	Not Unfitting 
	Kidney Stone Condition	7500	NSC	N/A	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back pain (LBP) began in November 2006 with no specific injury or trauma.  Radiographic studies performed in April 2007 and again in March 2008 showed a small bulging intervertebral disc at L4-L5 with no change between the dates of those studies. 

At the 18 June 2008 orthopedic examination, 6 months prior to separation, the CI complained of ongoing bilateral lumbar pain and stiffness that had been transiently improved by non-surgical treatment.  Physical examination showed a normal gait with a normal appearing spine, normal reflexes and sensory response, and normal strength.  The lower back was tender and muscle stiffness was noted in the lower back.  Range of motion (ROM) for the lumbar spine (rather than the VASRD-specified thoracolumbar ROM) was reported as flexion to 30 degrees (normal 60) with combined ROM of 80 degrees (normal 210).  Normal thoracolumbar ROM is 90 degrees flexion with combined ROM of 240 degrees.        

During the 25 June 2008 MEB NARSUM examination, the CI reported daily low back pain, rated 5-8/10 in severity, worsened by high-impact activities, lifting over 10 pounds, or repetitive bending.  Physical examination revealed a normal gait with normal strength and reflexes.  The back was tender and the examiner noted an absence of muscle spasm.  Back flexion, extension, rotation and lateral flexion were not measured, but it was noted that all ROM induced “very mild” painful motion. The 1 July 2008 physical therapy examination measured flexion as 55 degrees with combined ROM of 175 degrees, and all planes of motion limited by pain.    

There was no VA examination proximate to separation in evidence.  The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain at 20%, coded 5299-5237 (analogous to lumbosacral strain), citing limitation of flexion to 55 degrees.   The VA rated the back at 0%, coded 5237 based on a lack of available evidence.  The physical therapy examination provided the most detailed ROM which was also most proximate to the date of separation.  Based on that examination, the panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees).  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 that alternate VASRD formula.  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 chronic low back pain condition.  

Contended PEB Condition:  History of Right Nephrolithiasis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement, and did not fail retention standards.  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 contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic low back pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended history of right nephrolithiasis, the panel agrees it cannot recommend it for additional disability rating.  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 20210622, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20210017325, XXXXXXXXXXXXXX. 

Dear XXXXXXXXXXXXXXXXXXXXX:

	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,