RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-00870
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140520
Date of SEPARATION:  20080107

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (3P0X1/Security Forces Journeyman) medically separated for a back pain condition.  The injury occurred in 2005 from a HUMVEE rollover accident while he was deployed to Kyrgyzstan.  He failed to gain any long term relief from physical and chiropractic therapy or chronic pain medication.  The CI also had a medical history of adjustment disorder and depression.  His back condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued a temporary L4/S1 profile and referred for a Medical Evaluation Board (MEB).  The back pain condition, characterized as “chronic myofascial thoracic pain syndrome,” was forwarded to the Physical Evaluation Board (PEB) as not meeting medical standards IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated the chronic myofascial thoracic pain syndrome condition as unfitting, rated 10%, with application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “On 2 Oct 2007, the AF Informal Physical Evaluation Board recommended that I be discharged from Service with a disability rating of 10%, solely based on the unfitting condition of ‘Chronic Myofascial Thoracic Pain Syndrome'. I believe the board should have also considered my diagnosis of post concussive syndrome and TBI, as well as his severe Adjustment Disorder diagnosis and a more accurate diagnosis of bulging disc.”  During the IPEB, a line of duty determination was completed (AF IMT 348).  Veteran was diagnosed as having adjustment disorder, major clinical depression, post concussive syndrome and chronic back pain.  However, member believes these specific diagnoses were not properly adjudicated and the recommendation for medical discharge with severance pay should have been a recommendation for full medical retirement with a higher disability rating.  Since that time Veteran has been thoroughly examined and diagnosed by the Department of Veteran Affairs. More recently, the Dept of Veterans Affairs has properly attributed his initial AF IPEB rating of 'Chronic Myofascial Throracic (sic) Pain Syndrome as bulging disc at L4-L5 (NOTE: the symptoms of Veterans current bulging disc diagnosis is identical to those originally reported in Service at time IPEB).  Veteran was diagnosed by VA as having Traumatic Brain Injury (previously denoted as post concussive syndrome).  Veteran was diagnosed with a "continuation" of suffering from Adjustment Disorder "related to PTSD", due to Service related trauma and depressed moods after major motor vehicle accident.  Veteran prays that this board consider the aforementioned issues and believes this would just and in order.”

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 those conditions identified, but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting chronic myofascial thoracic pain syndrome is addressed below.  The contended adjustment disorder, depression, posttraumatic stress disorder, post-concussive syndrome and traumatic brain injury conditions were not identified by the MEB or PEB, and thus are not within the Board’s purview.  These, and any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

The Board acknowledges the impairment with which the CI’s service-connected conditions continue to burden him but notes the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions that resulted in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.

RATING COMPARISON:

Service IPEB – Dated 20071002	VA* - (8.7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Myofascial Thoracic Pain Syndrome	5099-5021	10%	Lumbar Spine Strain	5237	20%**	20080924	
No Additional MEB/PEB Entries	Other x 12	20080924	
Combined:  10%	Combined:  60%	
* Derived from VA Rating Decision (VARD) dated 20081015 (Initial VARD with lumbosacral rating)
** No change to rating derived from subsequent C&P exams

ANALYSIS SUMMARY:

Chronic Myofascial Thoracic Pain Syndrome.  After a motor vehicle rollover accident while deployed in November 2005, the CI had on-going complaints of pain in the back.  X-rays and computer aided tomograms of the spine done as part of his work up were normal without evidence of fracture or disc problem.  The MEB narrative summary (NARSUM) dated 24 May 2007, 7 months prior to separation, described in the physical examination that the CI demonstrated “…normal gait and station, normal transfer and balance, able to bend at waist and touch toes, able to sit up and crunch and straight leg raise without difficulty, non-tender over spine, spine straight, no paraspinal muscle spasm, no weakness or numbness in extremities, DTR intact bilaterally.” There was no finding in the NARSUM to suggest a peripheral nerve neuropathy.  The physical therapy (PT) clinic report of 16 August 2007, 5 months prior to separation, reported separate range-of-motion (ROM) examinations for the thoracic spine and lumbar spine using the dual inclinometer method (two inclinometers placed at specified locations on the spine enabling measurement of motion of specific spine segments between the two inclinometers) rather than measuring a combined thoracolumbar ROM using a goniometer as required for rating using the VASRD general rating formula for diseases and injuries of the spine.  The values recorded were for active ranges of motion.  The examiner recorded “Thoracolumbar spine motion was abnormal AROM for thoracic spine using dual bubble inclinometers” indicating isolated thoracic ROM using dual inclinometer method (one inclinometer placed at T1 and the second at T12).  Isolated lumbosacral spine motion was also measured using the dual inclinometer method (one inclinometer placed at T12 and one on the sacrum).  Combining the results approximates the combined thoracolumbar ROM using a goniometer.  Thoracic spine flexion was 20 degrees and the lumbosacral spine flexion was 86 degrees with pain starting at 75 degrees (normal combined thoracic and lumbar flexion is 90 degrees).  The thoracic spine extension was 7 degrees with lumbosacral spine extension of 23 degrees to give a sum of 30 degrees with pain beginning at 19 degrees (normal combined thoracic and lumbar extension is 30 degrees).  The recorded value for thoracic spine lateral flexion to the left was 21 degrees with a lumbosacral spine lateral flexion to the left of 18 degrees giving a sum of 29 degrees with pain starting at 15 degrees left lateral flexion (normal combined thoracic and lumbar lateral flexion is 30 degrees).  The thoracic spine lateral flexion to the right was 33 degrees with lumbosacral spine lateral flexion to the right of 18 degrees for a sum of 51 degrees with pain starting at 13 degrees of right lateral flexion.  Lateral rotation of either the thoracic or lumbar spines was not described in this examination by the physical therapy clinic.  The VA Compensation and Pension (C&P) examination on 19 March 2008, approximately 2 months after separation, recorded “lumbosacral spine” flexion of 40 degrees limited by pain, extension 20 degrees limited by pain, right and left lateral flexion of 30 degrees.  Gait, strength and reflexes were normal.  The VA C&P examination on 24 September 2008 recorded “lumbar flexion” of 40 degrees, extension 3 degrees, lateral bending of 15 degrees to both sides, and rotation of 10 degrees bilaterally.  There was complaint of pain with motion.  Straight leg raising was to 80 degrees with report of pain.  Spinal contour and posture was normal, without muscle spasm.  The CI reported pain with examination maneuvers that were not expected to cause pain based on the known pathology.  X-rays of the lumbosacral and thoracic spines performed at the time of the C&P examination were reported as normal.  A magnetic resonance imaging in 2011, 3 years after separation, demonstrated a mild disc bulge at L4-5 without nerve root compression.  Evaluation by physical medicine and neurosurgery at that time found no evidence of associated radiculopathy.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% coded 5099 – 5021, myositis (5021 rates analogously to 5003 which directs a rating based on limitation of motion or evidence of painful motion).  The VA rated the back condition 20% (coded 5237, lumbosacral strain), citing limitation of thoracolumbar ROM at the time of the September 2008 VA C&P examination.  The ROM documented at the time of the MEB NARSUM (touch toes) and the MEB PT examination (combined thoracic and lumbar motion) supported no more than a 10% rating under the general rating formula for diseases and injuries of the spine (these ROMs were non-compsenable).  A combined thoracolumbar ROM (i.e. flexion, extension, lateral bending and rotation added for a “combined” range of motion) could not be calculated in the absence of values for lateral rotation.  However, given the normal values provided for the documented ROMs at the PT clinic and in view of the lack of limitation recorded at the MEB NARSUM physical examination, we can extrapolate a combined thoracolumbar ROM that did not support a higher rating.  The Board noted the values for the thoracolumbar spine ROMs documented by the C&P examinations after separation were significantly lower than those recorded at examinations within the 12 months prior to separation and supported the 20% rating adjudicated by the VA.  However, there was no evidence of any intervening injury or known pathology to explain the decrease in motion therefore the Board considered the MEB examinations more consistent with the known pathology and more reflective of the disability at time of separation.  The MEB NARSUM stated the CI was able to do all functional activities of gait, balance, transfer, squat, sit up, crunch and touching toes without limitation.  There was no spasm causing altered gait or spinal contour to support a 20% rating.  There was no finding of intervertebral disc disease on any of the radiological studies in the service treatment record.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There is no evidence of radiculopathy with associated functional impairments that were separately functionally impairing in this case.  The Board therefore concludes that additional disability rating was not justified on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic myofascial thoracic pain syndrome 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 chronic myofascial thoracic pain syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				

SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2013-00870.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

Attachment:
Record of Proceedings