RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200917 SEPARATION DATE: 20050615 

BOARD DATE: 20130124 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SGT/E-5 (92F20/Petroleum Supply Specialist), 
medically separated for chronic low back pain (LBP). The CI’s chronic LBP began in September 
1999 when he fell from a confidence tower during training. He later reinjured it in 2004 in a 
minor motor vehicle accident while deployed to Afghanistan. The chronic LBP condition did not 
improve adequately with treatment 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 a Medical Evaluation Board (MEB). Mild posttraumatic stress 
disorder (PTSD), identified in the rating chart below, was also identified and forwarded by the 
MEB as meeting retention standards. The Physical Evaluation Board (PEB) adjudicated the 
chronic LBP as unfitting, rated 10%, with likely application of AR 635-40 B-29, and the Veterans 
Affairs Schedule for Rating Disabilities (VASRD). The PTSD condition was determined to meet 
retention standards and therefore to be not unfitting and not ratable. The CI made no appeals, 
and was medically separated with a 10% disability rating. 

 

 

CI CONTENTION: “Based on time for resolvement (sic) being 1 month and time spent for 
investigation was not adequate.” 

 

 

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 ratings 
for unfitting conditions will be reviewed in all cases. The PTSD condition as implied for 
consideration meets the criteria prescribed in DoDI 6040.44 for Board purview and is addressed 
below, in addition to a review of the ratings for the unfitting LBP condition. 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: 

 

Service IPEB – Dated 20050408 

VA (8 Mos. Post-Separation) – All Effective Date 20050614 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic LBP 

5237 

10% 

DJD, Lumbar Spine 

5010-5237 

10% 

20060215 

LRE Radiculopathy Assoc’d w/ 
DJD, Lumbar Spine 

8599-8520 

20% 

20060215 

Mild PTSD 

Not Unfitting 

PTSD 

9411 

10% 

20060322 

.No Additional MEB/PEB Entries. 

Stomach Ulcers w/ GERD 

7346 

10% 

20060215 

Lt Elbow Nerve Damage S/P 
Ulnar Nerve Transplant 

8599-8515 

10% 

20060215 

0% X 2 / Not Service-Connected x 1 

 

Combined: 10% 

Combined: 50% 



 

 


ANALYSIS SUMMARY: 

 

Chronic Low Back Pain Condition. The goniometric range-of-motion (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) 

MEB ~5 Mo. Pre-Sep 

VA C&P ~8 Mo. Post-Sep 

Flexion (90 Normal) 

(45) 42/46/43 

90 

Ext (0-30) 

(20) 20/22/22 

30 

R Lat Flex (0-30) 

(30) 34/28/30 

30 

L Lat Flex (0-30) 

(30) 40/44/44 

30 

R Rotation (0-30) 

(30) 36/36/34 

“0-180” per examiner 

L Rotation (0-30) 

(30) 37/32/30 

“0-180” per examiner 

Combined (240) 

185 

Not ascertainable 

Comment: VASRD 
Spine notes 2 and 4 
applied 

Pain with movement; tenderness, 
occasional radiation to R thigh; motor 
sensory and reflex exams normal 

No pain with ROM, no 
spasm, no paresthesia, 
normal gait 

§4.71a Rating 

20% (PEB 10%) 

10% 



 

At the MEB exam in January 2005, 5 months prior to separation, the CI reported constant 
aching pain in the middle of his lower back, with occasional pain and numbness radiating to his 
right thigh. His pain was increased by prolonged sitting or standing, running, lumbar flexion, 
and lifting moderately heavy objects. He reported no lower extremity weakness. He also 
reported a history of radiating numbness into the right thigh and 3-4 episodes of urinary 
incontinence during September 2004, without fecal incontinence. The MEB physical exam 
noted tenderness to palpation from L2-S1, tight paraspinal musculature, and a negative straight 
leg raise. The lower extremity muscle strength, sensation, and reflexes were normal. The ROM 
measurements are depicted in the chart, above. The average ROM for forward flexion was 45 
degrees, and the average combined thoracolumbar ROM was 185 degrees. Magnetic 
resonance imaging in September 2004 showed L4-5 dessication without disc protrusion or 
spinal stenosis. Lumbar spine X-rays, in September 2004, were normal. At the MEB addendum 
exam in March 2005, (3 months prior to separation), the CI reported chronic LBP ranging from 
6-8 out of 10 in intensity. The VA Compensation and Pension (C&P) exam in February 2006, 8 
months after separation, noted a normal spine exam, without joint swelling, effusion, or 
tenderness. The exam indicated: no pain with ROM; no muscle atrophy or spasm; no 
abnormalities of strength, sensation, or reflexes; no lower extremity paresthesia; a normal gait; 
no assistive aids; and no effects on activities of daily living resulting from lower back pain. The 
ROM was as in the chart, above. The exam cited a lumbar spine X-ray of unspecified date which 
showed normal alignment and configuration of the vertebral bodies. A lumbar myelogram with 
CT scan performed at a civilian hospital in June 2006, a year after separation, showed normal 
disc appearance, without significant bulge, herniation, stenosis, or foraminal encroachment. 
The PEB rated the low back condition coded 5237 at 10% citing “ROM studies indicate flexion of 
46 degrees; however, there is no evidence of mechanical block.” “Mechanical block” is 
referenced in AR 635-40, B-29, but is not considered in VASRD-only ratings. The VA Rating 
Decision (VARD) assigned a rating of 10% for code 5237, based on painful motion, without 
additional limitations related to fatigue, incoordination, weakness, or lack of endurance. An 
additional rating of 20% for code 8520 was assigned for lower right extremity radiculopathy, 
based on “incomplete paralysis below the knee.” 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
MEB exam was closer to the date of separation and the Board agreed that the MEB exam was 
more complete and held higher probative value for rating the chronic LBP at separation. The 
MEB disability picture also more closely aligned with the disability picture in the remainder of 
the treatment record. The MEB exam (and ROM noted on the PEB) meets the 5237 VASRD 20% 


rating criteria of “Forward flexion of the thoracolumbar spine greater than 30 degrees but not 
greater than 60 degrees.” The spine rating using the general rating formula for diseases and 
injuries of the spine is with or without symptoms such as pain (whether or not it radiates), 
stiffness, or aching in the area of the spine affected by residuals of injury or disease. There was 
no evidence of objective neurologic abnormalities associated with the chronic LBP condition on 
either the MEB or C&P exams, although the VARD indicated the C&P “exam showed decrease 
strength with pain causing a moderate affect of daily activities.” After due deliberation, 
considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt) and 
§4.7 (Higher of two evaluations), the Board recommends a disability rating of 20% for the 
chronic LBP condition. 

 

Other PEB Condition. The other condition forwarded by the MEB and adjudicated as not 
unfitting by the PEB was mild PTSD. PTSD was not profiled prior to, or at the time of, the MEB. 
No mental health condition was implicated in the commander’s statement as impairing the CI’s 
duty performance or noted as failing retention standards. PTSD was reviewed by the action 
officer and considered by the Board. The psychiatric narrative summary addendum indicated a 
diagnosis of anxiety disorder not otherwise specified. The examiner stated, “Psychologically, 
the patient suffers little to no impairment that would further impair his functioning in civilian or 
military life psychologically.” There was no indication from the record that the condition 
significantly interfered with the satisfactory performance of MOS duty requirements. After due 
deliberation in consideration of the preponderance of the evidence, the Board concluded that 
there was insufficient cause to recommend a change in the PEB fitness determination for the 
PTSD condition (or any other mental disorder condition) and so no additional disability rating is 
recommended. 

 

 

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. As discussed above, PEB 
likely reliance on AR 635-40, B-29, for assigning the 10% rating was apparently operant in this 
case and the condition was adjudicated independently of that policy by the Board. In the 
matter of the chronic LBP condition, the Board unanimously recommends a disability rating of 
20%, coded 5237 IAW VASRD §4.71a. In the matter of the mild PTSD condition, the Board 
unanimously recommends no change from the PEB determination as not unfitting. 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: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic Low Back Pain 

5237 

20% 

COMBINED 

20% 



 

 

 

 

 

 

 

 

 

 


The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120614, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for xxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130005078 (PD201200917) 

 

 

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 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 xxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)