RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX                                                                            CASE:  PD-2013-01931
BRANCH OF SERVICE:  AIR FORCE                                                               BOARD DATE:  20140716
Separation Date:  20050509

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (2S071/Supply Management Craftsman) medically separated for chronic low back pain (LBP).  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS) or satisfy physical fitness standards.  She was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  The LBP, left leg pain and piriformis conditions were characterized as “not meeting retention standards” and forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were identified by the MEB.  The informal PEB adjudicated “low back pain” as unfitting, rated 10% with cited application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were not noted on the PEB document, and are presumed to be not unfitting.  The CI made no appeals, and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her application.

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 LBP condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20050323	VA - (4 Mos. Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	10%	Lumbar Intervertebral Disc Syndrome	5243	10%	20050926	
			Radiculopathy, Left Lower Extremity	8520	10%	20050926	
			Radiculopathy, Right Lower Extremity	8520	10%	20050926	
No Other MEB/PEB Entries	Other x1 (Not in Scope)	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20051216 (most proximate to date of separation)

ANALYSIS SUMMARY:

Chronic Lower Back Pain Condition:  The CI injured her back after she tripped over a trailer hitch and fell backwards on 16 October 1997.  Thoracic and lumbar spine X-rays were both normal.  The CI was referred to Physical Therapy (PT) for left hip and LBP.  A bone scan was also normal.  A repeat lumbar spine X-ray done for reported pain radiating into the ankles bilaterally showed findings that were suggestive of congenital spinal canal stenosis.  A lumbosacral spine MRI was normal.  The CI had an electromyelogram (EMG) and a nerve conduction study (NCS) done on 30 April 2003 which were normal.  The CI was given an initial epidural steroid injection in April 2003.  The orthopedist noted that the CI had LBP as well as bilateral buttocks and hip pain.  The physical exam findings were tenderness over the sacroiliac joints bilaterally and tenderness throughout the lumbar spine and some midline tenderness to palpation.  There were no focal, motor or sensory deficits.  The CI was evaluated by pain management and given a second epidural steroid injection.  She was seen in follow-up by orthopedics and reported that she had some short term pain relief, however the symptoms had returned.  The CI was given a third epidural steroid injection on 3 October 2003.  She was thoroughly evaluated by neurosurgery for complaints of constant sharp back pain 10 out of 10 and constant sharp pain that radiated down her hips and down her legs with numbness and tingling in her left leg.  The three epidural steroid injections did not provide long-term pain relief.  The physical exam findings were patchy areas of diminished sensation in the right lower extremity, normal reflexes, normal muscle tone, negative straight leg raises and no palpable tenderness over the lumbar facets.  However, there was left hip pain with flexion/abduction and no pain radiation into the groin.  The examiner recommended a myelogram with flexion/extension views of the lumbar spine which demonstrated mild disc space narrowing at L4-5 with a mild right sided disc bulge.  The CI was given a temporary L4 Profile with additional specific restrictions.  The commander’s statement documented that her medical condition did not affect her work performance as she continued to work full shifts without hesitation.  The commander further stated that the CI was highly motivated to overcome her condition and he highly recommended her retention in the USAF with cross-training into another career field.  The MEBs’ narrative summary (NARSUM) exam approximately 4 months prior to separation documented that the CI had chronic LBP, left leg pain and piriformis syndrome without long-term relief despite undergoing multiple treatment modalities.  The MEB NARSUM physical exam findings are summarized in the chart below.  The VA Compensation and Pension (C&P) exam, approximately 5 months after separation, documented that the CI had daily pain across the back that radiated into the hips and buttocks down to the posterior thighs and knees.  She required the pain medication Tramadol 4 times a day and was unable to sit or drive for more than 30 minutes or to walk more than a half mile.  She had flares once or twice monthly with no additional activity restrictions.  The physical exam findings are noted in the chart below.

There were two range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Thoracolumbar ROM (Degrees)	NARSUM ~4 Mo. Pre-Sep	PT ROMS 3 Mos. Pre-Sep	VA C&P ~4.5 Mo. Post-Sep	
Flexion (90 Normal)	-	35	90	
Combined (240)	-	100	240	
Comment	Pos. painful motion; Normal gait; No tenderness to palpation; Normal strength, reflexes &b sensation; Neg. straight leg raise	Pos. painful motion	Pos. painful motion; Normal gait; No tenderness or spasm; Neg. straight leg raise; Normal strength; No Deluca criteria	
§4.71a Rating	-	20%	10%	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the chronic LBP condition as 5237, lumbosacral or cervical strain, and rated at 10%.  The VA coded the lumbar intervertebral disc syndrome (also claimed as chronic LBP, herniated disc, and disc bulge) condition as 5243, intervertebral disc syndrome, and rated at 10%.  The General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “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.”  The PT ROM values obtained 3 months prior to separation are consistent with a 20% rating while the C&P exam performed over 4 months after separation are consistent with a 10% rating.  The remainder of the evidence present for review does not support one rating over the other and there is no evidence to account for the discrepancy.  As both exams were equally detailed, the Board adjudged the pre-separation evidence to be the most probative for its rating recommendation.  The CI had no periods of incapacitation and was able to adequately perform her military duties within the scope of her profile.  Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  The sensory component in this case has no functional implications, there was no motor impairment, and her EMG/NCS tests were negative.  Since no evidence of functional impairment exists in this case, the Board cannot support a recommendation for additional rating based on peripheral nerve impairment.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the LBP 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 LBP condition, the Board unanimously recommends a disability rating of 20%, coded 5327 IAW VASRD §4.71a.  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 her 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 20131023, 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-2013-01931.

	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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

							

Attachments:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR