RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-01530
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141021
SEPARATION DATE:  20070730

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (3P051/Security Forces Journeyman) medically separated for a lower back condition.  This condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P4 profile and referred for a Medical Evaluation Board (MEB).  The low back pain (LBP) condition was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated the LBP due to osteoarthritis as unfitting, rated 10%, with application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “TMJ diagnosed in the military.  I was referred surgery through the dental office but denied because my 1st Sergeant would not let me have time off due to deployability.  It still pains me, hard to chew and bate [sic] certain foods and pops.  I don’t have the money as a single dad to afford dental procedures, that could have been performed while active duty.  Degenerative Joint Disease – 10% seems low being the ? [sic] it at bulges, arthritis, and pain associated.  I still have pain, and weakness currently daily, taking pain meds and muscle relaxers on top of seeing a chiropractor, considering it been a year before recovering enough for a job after separation.  Hypertension – high readings in the military continuing now through VA and local doctors 180s/80, ? [sic] Military and VA would not treat until a private doctor made me go on meds.  Athletes foot – after deployments this has started and still presents a problem.  Yellowing and fungus of the nails and they fall off.  Sometimes scratching my skin off until bleeding.  Hemorrhoids & IBS – constant hard stools and diarrhea since 2000s.  Bleeding persistent often needing a pad – loose and explosive bowels.  3 colonoscopies, one saying colitis and hemorrhoids, most recent showing internal hemorrhoids.”  The CI attached a two page statement to his application which was reviewed by the Board and considered in its recommendations. 

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 back condition is addressed below.  Temporomandibular joints, degenerative joint disease (DJD), hypertension, athlete’s foot and hemorrhoids and irritable bowel syndrome were contented, but these were not identified by the MEB or PEB; and, thus are not within the DoDI 6040.44 defined purview of the Board.  These, and any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.  

RATING COMPARISON:

Service IPEB – Dated 20070612	VA* - (2.1 Mos. Pre -Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5003	10%	Lumbar Spine Disorder…	5237	NSC**	20070529	
Other x 0 (Not in Scope)	Other x 17	20070529	
Combined:  10%	Combined:  0%**	
*Derived from VA Rating Decision (VARD) dated 20070918 (most proximate to date of separation (DOS))
**VARD 20080709 rated degenerative joint and disc disease, lumbar spine (5242-5003) at 10% and left leg sciatic nerve (8520) at 10% effective 20070731 one day after DOS based on exam of 20080331.

ANALYSIS SUMMARY:  The Board acknowledges the CI’s sentiment regarding the significant impairment with which his medical conditions continue to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.

Low Back Pain.  The record indicates that the CI had insidious (no single specific trauma) onset of LBP with pain radiating down the left leg to the knee level.  Conservative treatment including medications, injections and myelogram were not effective and the CI was not considered a surgical candidate.  Magnetic resonance imaging (MRI) and bone scan imaging documented degenerative disease, moderate canal stenosis and mild disc bulges in the lumbar spine “without impacting any neural structures.”  Plain X-rays were normal.  Electrophysiologic study demonstrated evidence of chronic radiculopathy at the L4 level.  “There is no evidence of neuropathy.”  At the MEB narrative summary (NARSUM) examination performed approximately 3 months prior to separation, the examiner documented tenderness and “lumbosacral spine flexion was abnormal with guarding occurring at 10 degrees off vertical, due to reported pain, otherwise deferred after PM [primary care] and R [rheumatology] and Neurosurg eval's earlier with symptoms currently unchanged (see the specialty evaluations for additional physical findings) extension was normal.  Lumbosacral spine exhibited no muscle spasms.”  Gait and stance were normal, as was the peripheral nerve exam (strength, reflexes, and coordination).

At the VA Compensation and Pension (C&P) exam performed approximately 2 months prior to separation, the CI reported low back pain, stiffness, weakness (“hard to bend or lift objects”) and spasms.  Pain was constant and radiated down the left leg to the knee.  “He states his spine condition does not cause incapacitation.”  The exam documented full, painless range-of-motion (ROM) of the thoracolumbar spine with no evidence that ROM was additionally limited by pain, fatigue, weakness or lack of endurance following repetitive use.  Gait and neurologic exams were normal.  X-rays were reported as normal.  Physical therapy evaluation, less than 2 months prior to separation, documented pain-limited thoracolumbar motion as charted below.  At the VA C&P exam dated, approximately 8 months after separation, the CI reported back pain with motion, flares and weakness if he tried to lift over 50 pounds.  Exam documented painful motion on flexion from 80-90 degrees.  Gait and lower extremity neurologic exams were normal.  MRI abnormalities indicated disc bulge, canal stenosis and degenerative changes.

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

Thoracolumbar ROM
(Degrees)	NARSUM ~3Mo. Pre-Sep	VA C&P ~2 Mo. Pre-Sep	PT ~2 Mo. Pre-Sep	VA C&P ~8 Mo. Post-Sep	
Flexion (90 Normal)	“Guarding occurring at 10⁰ off vertical” (with pain)	90	(70) 68/66/68	80	
Combined (240)	Unk/incomplete--	240	220	230	
Comment	“otherwise deferred”; painful motion; tenderness	No painful motion; normal gait; normal peripheral nerve exam	Tender; painful motion	“Pain from 80-90⁰ flexion”	
§4.71a Rating	10%-40%	0% (VA NSC)	10%	10% (VA 10%)	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB utilized code 5003 (arthritis, degenerative) at 10% and the VA utilized codes 5242-5003 (degenerative arthritis of the spine and arthritis, degenerative) at 10%, then 5003-5237 (arthritis, degenerative and lumbosacral strain) to code the back pain, but they assigned the same 10% rating percentage following an additional post-separation VA examination.  The MEB NARSUM ROM values were incomplete and the flexion measurement was not consistent with outpatient notes, causing diminution of its probative value.  Two subsequent pre-separation exams from physical therapy (PT) and VA C&P documented normal or near-normal ROMs.

The Board determined that the ROMs from the PT exam which was closest to separation held greater probative value than the single incomplete MEB NARSUM measurement.  Symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected is considered under the General Rating Formula for the Spine which includes all diagnoses under codes 5235-5234 which include DJD, stenosis and intervertebral disc syndrome.  There was insufficient evidence of forward flexion of the thoracolumbar spine limited to 60 degrees or less (or combined 120 or less) or of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour to warrant a rating higher than 10% under the general spine formula.  There were no periods of incapacitation for any higher alternative rating under the formula for rating intervertebral disc syndrome using code 5243.  There was no documented lower extremity weakness or non-pain duty-limiting radiculopathy on any exam, or in the Service treatment record.  The Board adjudged that there was not a preponderance of the evidence for addition of an unfitting peripheral nerve condition.  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 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 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 20140401, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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-2014-01530.

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,

XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings