RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00393
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Services Craftsman, medically separated for “chronic low back pain associated with degenerative disc disease,” with a disability rating of 10%.  

CI CONTENTION:  Her condition continues to worsen and negatively impact her daily activities.  The applicant’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited 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 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 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 based upon a 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 PEB - 20060324	VARD - 20070308	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5243	10%	Lumbar Strain	5237	10%	20061128	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain Associated with Degenerative Disc Disease.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in July 2002 after heavy lifting, and was aggravated in October 2003 after falling.  Chronic back pain was associated with right lower extremity radiating pain diagnosed in 2004 as a radiculopathy.  Magnetic resonance imaging (MRI) studies in June 2004 showed minimal bulging discs from L3 to S1, but without nerve or spinal cord impingement.  There was no surgical indication.  Despite conservative treatment and therapeutic injections, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic low back pain” for PEB adjudication.

A primary care clinic examination on 23 May 2005 (12 months prior to separation) noted forward thoracolumbar flexion of 45 degrees (normal 90).  A follow-up primary care entry on 21 November 2005 (6 months prior to separation) reported a complaint of “rare” radiating pain to the right lower extremity.  The physical therapy (PT) examination performed on 10 January 2006 (4 months prior to separation) showed thoracolumbar flexion after 3 repetitions of 40 degrees and a combined range of motion (ROM), after 3 repetitions in all planes, of 110 degrees (normal 240).  Painful motion was present.

The MEB NARSUM examination in February 2006 (approximately 3 months prior to separation) noted complaints of chronic low back pain with discomfort when sitting or standing for prolonged periods, and tingling and pain in the right buttocks.  Physical examination showed a non-antalgic gait with normal motor strength, reflexes and sensation.  There was no tenderness.  A test for possible nerve root irritation was positive on the right. 

At the VA Compensation and Pension (C&P) examination on 18 November 2006 (6 months after separation) the CI reported constant, sharp, stabbing 10/10 pain which radiated to the right leg.  At the time of pain, she could function with medication.  There was associated right buttock numbness.  She related four instances of incapacitating episodes during the previous year lasting 15 days total.  Physical examination showed a normal gait without use of assistive devices for ambulation.  There was no evidence of radiating pain on movement of the spine, and no muscle spasm or ankylosis.  Spine tenderness and painful motion were present.  Testing for possible nerve root irritation was negative bilaterally.  Forward flexion was 85 degrees and combined ROM 235 degrees.  There was no change in ROM with repetition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10% coded 5243 (intervertebral disc syndrome).  The VA rated the lumbar strain condition 10% coded 5237 (lumbosacral strain), based on the VA C&P examination citing limitation of forward flexion and combined ROM.  Members agreed that the only service ROM measurements in evidence (12 months and 4 months prior to separation) supported a 20% rating, but no higher, for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) and combined ROM (not greater than 120 degrees).  Although the VA examination supported a 10% rating for limitation of motion, the Board concluded that the clinical picture at the time of separation was most accurately described by the pre-separation data, which as noted above, justified a 20% rating. 

The Board also considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome (IVDS).  Although the CI had intervertebral disc disease there was no documentation of a sufficient number of incapacitating episodes (physician-prescribed bed rest) to warrant a higher rating under the alternate VASRD formula (for IVDS).  The Board finally considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  While a diagnosis of radiculopathy was present in the STR, all neurologic examinations proximal to separation were normal.  There was no objective evidence of functional impairments attributable to radiculopathy, such as lower extremity muscle weakness.  Moreover, 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).”  The Board therefore concluded 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 recommends a disability rating of 20% for the chronic low back pain associated with degenerative disc disease, coded 5243.  
BOARD FINDINGS:  In the matter of the chronic low back pain condition associated with degenerative disc disease condition, the Board recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior to medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain associated with Degenerative Disc Disease	5243	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140110, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00393.

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.

Sincerely,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR