RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01113
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Tactical Aircraft Maintenance Craftsman, medically separated for “chronic thoracic back pain,” with disability rating of 10%.  

CI CONTENTION:  The applicant makes no specific contentions.  The 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 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 PEB - 20090127	VARD - 20100427	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Thoracic Back Pain	5299-5237	10%	Thoracolumbar Strain with degenerative Disc Disease…	5243	10%	20091229	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY

Chronic Thoracic Back Pain.  According to service treatment records, the CI’s thoracic back pain condition began in early 2007 after a friend jumped on his back.  Magnetic resonance imaging (MRI) in January 2008 showed early degenerative disc changes with no significant disc protrusion, canal stenosis or cord flattening and a slight rightward curvature of the lower thoracic and upper lumbar spine.  

At the time of an initial pain management consult on 15 May 2008, performed 13 months before separation, the CI reported sharp, stabbing and dull 6/10 thoracic back pain exacerbated by bending, lifting and lifting.  On examination gait was within normal limits, and lower extremity strength, sensation, and reflexes were normal.  There was tenderness to palpitation (TTP) around the T6-T7 levels.  The diagnosis was thoracic degenerative disc disease (DDD) and a series of epidural steroid injections (ESI) were recommended

At a family practice clinic visit on 23 July 2008, performed 10 months before separation, the CI indicated he was scheduled for his second ESI the next day.  Additionally, he reported he tried “adjusting” himself and developed LBP radiating into his left lower extremity (LLE), without weakness or numbness.  On examination normal gait and posture were noted.  There was TTP to the lumbosacral spine and left sciatic notch (area of buttock where sciatic nerve is close to surface).  His gait was normal, there were no muscle spasms and normal strength.  The CI reported continued LBP and LLE pain at a family practice visit on 29 October 2008.  There was no imaging of the lumbar spine in record or referenced in the STR.  The CI was treated for LBP with medication and referred to a chiropractor.  

There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The Medical Evaluation Board (MEB) forwarded “chronic thoracic back pain” for PEB adjudication.

At the time of the physical therapy examination for the MEB on 22 October 2008, performed 8 months before separation, the thoracolumbar (TL) range of motion (ROM) was forward flexion of 65 degrees (90 degrees normal) and a combined ROM of 195 degrees (240 degrees normal); there was pain at all end ranges.  Neither the narrative summary (NARSUM) examination nor the DD Form 2807-1 and DD Form 2808 are in the available record.  A neurology consult performed on 6 November 2008 noted thoracic back pain with occasional numbness of the midline upper thoracic spine that radiated bilaterally.  The examiner noted “limb weakness subjective and numbness subjective.”  The examination noted normal gait and posture, and normal strength, and reflexes of all extremities and decreased sensation of the right hand that did not conform to “any particular [nerve or nerve root] distribution.”  The assessment was musculoskeletal pain.  Cervical MRI and right upper extremity electro-diagnostic studies were performed following the neurological consult and were both normal studies.  

At the VA Compensation and Pension (C&P) examination on 29 December 2009, performed 7 months after separation, the CI reported 5/10 thoracic pain describe as a dull ache with occasional stabbing pain with flares once a week with 10/10 pain; 3/10 lumbar pain described as a dull tightness with flares twice a month with 6/10 pain.  Pain was precipitated by moving “wrong,” walking, bending and prolonged sitting.  He additionally reported radiation, stiffness and weakness in all areas.  The physical examination showed a normal gait with a slight leaning forward posture of the head and flattened spinal curvatures with normal motion.  There was tenderness to palpation of the paraspinal muscles.  Motor strength was normal in both the UE and LE with normal reflexes and sensory functions grossly intact.  The examiner noted no incapacitating episodes in the past 12 months.  The forward flexion was 80 degrees with a combined ROM of 210 degrees, with pain, fatigue and lack of endurance after repetitions, but no loss of coordination or additional limitation of motion due to pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic thoracic back pain condition 10% coded analogous to 5237 (lumbosacral strain), citing limitation of motion.  The VA rated the thoracolumbar strain with degenerative disc disease condition 10% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 7 months after separation, citing limitation of motion.  

The Board noted that the CI was medically separated for thoracic back pain, but proximate to separation also reported low back pain that radiated to the LLE.  However, according to the VASRD rating guidelines for the spine in effect on the date of separation, only one rating may be provided for the thoracolumbar spine.  
The Board agreed that a 10% rating, but no higher, was justified for limitation of TL flexion (greater than 60 degrees but not greater than 85 degrees) or combined TL range-of-motion (greater than 120 degrees but not greater than 235 degrees) reported on the MEB physical therapy and VA examinations.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  While the CI reported radiating pain and numbness from the TL back condition (thoracic pain, numbness and lumbar LLE pain), radiating pain is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates), and there was no objective evidence of a radiculopathy (thoracic or lumbar) with functional impairments such as objective weakness or sensory deficits with a direct impact on fitness that were separately functionally impairing for duty.  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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic thoracic back pain condition.  

BOARD FINDINGS:  In the matter of the chronic thoracic back pain 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.  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 20140303, 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-2014-01113.

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