RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00270
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141216
SEPARATION DATE:  20060601

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Security Forces Journeyman) medically separated for a back condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty.  He was issued a temporary P3 profile and referred for a Medical Evaluation Board (MEB).  “Chronic low back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated “degenerative disc disease (DDD) associated with low back pain” as unfitting, rated 10% with presumed application of the VA Schedule for Rating Disability (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Conditions continue to worsen.  Diagnosed with scoliosis and documented in Medical Records.  Discharge decision based on Lower Back only and not whole Back and Neck.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Service IPEB – Dated 20060405	VA - (3.5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Disc Disease associated with Low Back Pain	5243	10%	Thoracolumbar Strain with Osteophytes, Degenerative 
Joint and Disc Disease, and Wedging and Disc Bulging	5243	20%	20060919	
Other x 0 (Not in Scope)	Other x 1	
Rating:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20070320 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Low Back Condition.  The narrative summary (NARSUM) noted the CI had a history of more than 4 years of back pain and had first presented to the clinic in September 2004.  Lumbar spine magnetic resonance imaging (MRI) on 28 December 2005 showed multilevel DDD without evidence of spinal canal narrowing or nerve impingement.  A chiropractic note on 24 January 2006, approximately 4 months prior to separation, noted the CI “moves without much apparent distress or guarding.”  A pain management consultation on 3 March 2006 the CI had a normal gait and listed current medications of anti-inflammatory, pain and nerve related pain medications (Ibuprofen, Percocet, Gabapentin).  On examination there was mild tenderness to palpation (TTP) and a negative straight leg raise (SLR) test.  According to the NARSUM, despite treatment with multiple medications, chiropractic treatments, pain management consultation, and epidural steroid injections the CI experienced only partial or temporary improvement of his back pain.

At the MEB examination on 3 March 2006, approximately 3 months prior to separation, the CI reported upper and lower back pain without weakness or neurological problems.  Current medications were ibuprofen, Percocet, and pregabalin (Lyrica).  The MEB physical exam noted TTP of the upper and lower spine and surrounding muscle without spasm.  Back range-of-motion (ROM) was noted as “decreased forward flexion due to midline pain.”  Lower extremity (LE) strength, sensation, and reflexes were normal.  Physical therapy measured “Lumbar Active Range of Motion” in the record, undated but which appears to have been performed for the MEB, indicated flexion of 99 degrees with a combined ROM of 178 degrees and noted that a bubble goniometer was used for the measurements.  The therapist noted that the measured left and right rotation of 9 degrees (TL normal 30 degrees) “is purely at the lumbar level without account to Thoracic rotation which accounts for 80% of full rotation.”

At the VA Compensation and Pension examination on 19 September 2006, performed 3 months after separation, the CI reported back pain that occasionally radiated to his left hip.  He was noted to be employed as a security guard, had not missed any work, and denied any incapacitation or prescribed bed rest in the past year.  On examination, his gait was normal.  SLR testing was reported as positive bilaterally.  Normal heel and toe walking, no additional loss of ROM was noted with repetitive movements.  Back ROM was flexion of 90 degrees, and combined ROM of 240 degrees, with painful motion.  LE strength, sensation, and reflexes were normal and the examiner noted, “No evidence of any radiculitis on examination.”  The original VARD on 20 March 2007 referenced lumbar MRI 2003 and thoracic MRI 2005 results, which showed DDD; lumbar X-rays which showed straightening of the lumbar curvature and multilevel arthritis; and, thoracic x-rays, which showed “mild wedging.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5243 (intervertebral disc syndrome) and the VA rated it 20%, coded 5243, citing X-ray evidence of the straightening of the lumbar curvature as “objective evidence of muscle spasm.”  The Board agreed that the back condition met a 10% rating IAW §4.59 (painful motion).  The Board next considered if a higher rating was achieved based upon the ROM values in record.  Physical therapy (PT) measured a combined “lumbar” ROM of 178 degrees and flexion of 99 degrees.  The PT examiner noted use of a “bubble goniometer,” which is a small refinement of a goniometer by the attachment of a level, but indicated that rotation values were for the lumbar spine only which suggests use of a “bubble inclinometer,” yet the flexion value of greater than 90 degrees includes the thoracic contribution (pure lumbar ROM is 60 degrees).  The PT ROM values were not documented per current VASRD guidelines, which specify measurement of thoracolumbar ROM with a goniometer and how these measurements were taken is unclear to the Board.  However, members considered that this was a moot issue since even as measured, which underestimates combined TL ROM, neither the PT flexion or combined ROM values exceed the 10% rating according to current VASRD rules for spine rating in effect at the time of separation, specified as “forward flexion of the thoracolumbar spine of greater than 60 degrees but not greater than 85 degrees…or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees…”  The Board next reviewed the VA rationale for a 20% rating based on the X-ray findings noted.  However, the Board noted that there was no evidence of muscle spasm noted on any examination in record.  While acute muscle spasm can cause a straightening of the lumbar curve this can also be due to developmental abnormalities or degenerative disease of the thoracolumbar spine and the evidence did not support the conclusion that the noted lumbar flattening on imaging was due to muscle spasm.  Additionally, there was no evidence in record of incapacitating episodes or peripheral nerve impairment due to the back condition to provide for higher or additional rating.  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 low back 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 low back 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 20140106, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2014-00270.

	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,

XXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings