RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00500
BRANCH OF SERVICE:   AIR FORCE  	BOARD DATE:  20150721
SEPARATION DATE:  20060216

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Basic Airman) medically separated for a mild compression fracture of her lumbar spine.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).   She was issued a duty restriction from training and referred for a Medical Evaluation Board (MEB).   The “compression fracture L-1” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123, 36-3212 and 41-210.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “mild compression fracture, L1 vertebral body” as Category I: unfitting, rated 10%, citing Department of Defense and Veterans Affairs Schedule for Rating Disabilities (VASRD) guidelines.  Of note, the PEB cited the CI’s non-compliance with prescribed treatment for her back condition, however there is no evidence of a rating deduction made by the PEB for said non-compliance.  The CI made no appeals and was medically separated.    

CI CONTENTION:  “A lot of issues with lower part of my back and my right knee”.

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 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:  

IPEB - Dated 20060209	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mild Compression Fracture, L1 Vertebral Body	5235	10%	Residuals, L1 Compression Fracture	5235	10%	20060620	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING: 10#%	
*Derived from VA Rating Decision (VARD) dated 20060809 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY: 

Lower Back Condition.  The service treatment record (STR) documents that the CI sustained a fall during the confidence course.  She experienced acute onset of back pain and was evaluated in the emergency department (ED).  At the 29 August 2005 orthopedic surgery evaluation, the CI complained of increasing back pain after falling approximately 10 feet off an obstacle on 22 August 2005.  She had been seen in the ED and diagnosed with a lumbar vertebra (L2) compression fracture.  All other studies were negative.  She reported pain, especially with rest and activity, but denied radiating pain, numbness, tingling, or bowel/bladder dysfunction.  The physical exam revealed a normal gait and recorded tenderness to palpation over the paraspinal musculature, with no specific spinous process tenderness.  Active range-of-motion (ROM) of the trunk revealed forward flexion and side bending to the knee level.  Seated and supine straight leg raising (SLR) tests (assess sciatic nerve root compression by a herniated disc) were negative.  She was neurovascularly intact.  The lumbar X-rays were consistent with a 10-15% L2 compression fracture.  The assessment listed an L2 compression fracture.  The CI was started on an NSAID (Naprosyn), a muscle relaxant (Robaxin), a back brace, and a profile.  The 18 October 2005 orthopedic spine clinic consultation recounted the history of fall and injury.  The CI reported 5-6/10 pain, gradually resolving symptoms, and taking a muscle relaxant (Robaxin) and NSAID (Naprosyn).  She denied any lower extremity symptoms or bowel or bladder dysfunction.  The CI had been issued a back brace but had not worn it because “it was uncomfortable.”  The physical exam revealed mild paraspinal muscle tenderness and no masses or deformities.  The ROM recorded limitation of both flexion and extension due to low back pain.  Sensation, strength (5/5), and deep tendon reflexes (2+) were normal.  The SLR tests were negative.  The 18 October 2005 lumbar spine X-ray showed a mild compression of the L1 vertebral body.  The assessment listed a healing L1 compression fracture without worsening deformity.  The orthopedic surgeon recommended no surgical intervention, one more month of brace wear, and an entry level separation.  The surgeon opined that “symptoms following a traumatic compression fracture in her age group may take 3-6 months for her symptoms to resolve.”  The narrative summary (NARSUM), 4 months before separation, related the history of injury and interventions to date.  The CI failed conservative therapy (activity modification, medications, and a back brace) and was not deemed a surgical candidate.  It documented “The orthopedic spine specialist … recommended … she be separated … stating her injury could take approximately 3-6 months to heal.”  The NARSUM recounted the findings from the 18 October 2005 orthopedic spine clinic physical exam.  On 8 February 2006 physical therapy (PT) measured lumbar spine range-of-motion (ROM) for the MEB.  The CI was unable to perform to full ROM secondary to complaints of increased pain.  The pain-limited ROM values are in the chart.  The compensation and pension (C&P) exam, 4 months after separation, recounted the history of the traumatic L1 compression fracture.  The CI reported intermittent symptoms with remissions.  She was previously taking Robaxin and Naprosyn, but was unable to take medications due to pregnancy.  The CI complained of low back pain with prolonged standing and sitting and rotation and twisting.  She reported moderately severe weekly flare-ups which lasted for hours.  The CI reported her symptoms had mild effects on chores, exercise, and recreation and prevented sports.  The physical exam revealed a normal gait, good posture, and no deformity.  The back exam revealed L1 and paraspinal muscle tenderness.  There was no abnormal spinal curvature, ankylosis (joint stiffening or immobility), or fracture residuals.  There was no muscle weakness, atrophy (wasting), or spasm.  There were no neurogenic abnormalities associated with disc syndrome to include motor, sensory, bowel, or bladder abnormalities.  Goniometer measured lumbar spine ROMs are in the chart.  There was discomfort at 90 degrees flexion and with standing erect from forward flexion.  There was no additional limitation of motion on repetitive use due to pain, fatigue, weakness, or lack of endurance.  Motor, sensory, and deep tendon reflex exams were normal. 

The ROM evaluations which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

DOS 20060216
Thoracolumbar ROM
(Degrees)	MEB ~4 Mo. Pre-Sep
(20051018)	PT ~1 Wk. Pre-Sep
(20060208)	VA C&P ~4 Mo. Post-Sep
(20060620)	
Flexion (90 Normal)	“Limitation”	45	90	
Combined (240)	#	135	240	
Comment	AO	Pain	Discomfort 90° Flexion	
§4.71a Rating	#%	20%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB, a week before separation, rated the lower back condition at 10% (VA code 5235; vertebral fracture or dislocation).  The PEB cited healing of the L1 vertebral body fracture, improving symptoms, and that the CI was not fully compliant in wearing the brace as prescribed.  The VA rating decision (VARD) rated the lower back condition at 10% (5235).  The VARD cited the C&P exam, four months after separation, normal ROM, and residual pain from the healing fracture.  The orthopedic surgeon opined that “symptoms following a traumatic compression fracture … may take 3-6 months for … symptoms to resolve.”  A vertebral body fracture, with loss of 50% or more of the height, is consistent with a 10% rating under the VASRD general rating formula for diseases and injuries of the spine.  Board members agreed that the vertebral body compression, with loss of 10-15% height by X-ray, did not achieve this 10% rating.  The limitation of motion in the PT (MEB) exam was consistent with a 20% rating based upon the VASRD general rating formula for diseases and injuries of the spine.  Following the predicted period for recovery, the C&P exam demonstrated normal ROM consistent with the 0% rating.  The Board assigned more probative value to the C&P exam as it reflected findings after an appropriate period of convalescence.  The PT ROM measurements reflected limitations in the context of the acute injury.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of muscle spasm, abnormal spinal contour, or abnormal gait. The CI consistently denied signs of radiculopathy/neuropathy (radiating lower extremity symptoms or bowel or bladder dysfunction) and provocative tests (SLRs) showed no evidence of nerve root compression by a herniated disc, thus there was no preponderance of evidence to support consideration of a separately unfitting radiculopathy as related to the CI’s spine disability.  There was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45; and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  The Board agreed a 10% rating was supported based on functional loss (§4.40) or painful motion (§4.59).  After due deliberation, considering all of the evidence, and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the lower 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 lower 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 20140112, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

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

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00500.

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,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR