RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01702
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20091027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aerospace Medical Service Journeyman, medically separated for “low back pain” with a disability rating of 0%.  

CI CONTENTION:  The CI contends that his conditions (back, neck, and migraine headaches) continue to worsen and negatively impact his daily activities.  The CI’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 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 - 20090702	VARD - 20100127	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	0%	Chronic Dorsolumbar Sprain	5237	0%	20091110	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Low Back Pain Condition.  According to service treatment records, the CI’s back condition began in 2004 without any specific injury or trauma noted.  The CI reported thoracolumbar back pain that occasionally radiated to the left thigh.  Lumbar spine X-rays in March 2006 were normal and lumbar MRI in September 2006 showed degenerative disc disease and mild degenerative facet joint changes, with evidence of congenital spinal stenosis.  An orthopedic specialist recommended physical therapy (PT), which the CI attended without significant benefit.  At intermittent family practice clinic examinations in the record the CI was noted to have tenderness to palpation (TTP) of thoracolumbar spine and painful motion.  At the time of the spine evaluation 16 February 2009, the examiner recorded that the CI had “no radiculopathy and no lower extremity numbness tingling or weakness.”  On examination of the spine the CI had “full range of motion, no palpable lumbar paraspinal muscle spasm, point tenderness, or trigger points.”  There was a normal gait and lower extremity (LE) strength, reflexes, and sensation were all normal.  The neurosurgeon diagnosed “chronic mechanical low back pain.”  Four chiropractic visits in April 2009, before and after the spine evaluation, noted TTP of the spine from the upper back to the sacrum and painful ROM, with trigger points of the gluteal muscles bilaterally.  Despite treatment, 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 Medical Evaluation Board (MEB).  The MEB forwarded “chronic low back pain with occasionally left radiculopathy” for PEB adjudication.

The MEB narrative summary (NARSUM) examination on 9 April 2009 (7 months prior to separation) noted complaints of worsening back pain “exacerbated by flexion and extension of back” and occasional radiating pain of the left LE.  Physical examination showed a normal gait.  There was no TTP noted and normal ROM.  Lower extremity examination was normal and straight leg raise testing (SLR) was negative.  The MEB NARSUM examination noted the CI was not a surgical candidate and referenced an attached orthopedic consultation; however, the attached specialty report appeared to be the spine evaluation performed in February 2009 noted above.

An undated physical therapy ROM examination was labeled “MEB ROM evaluation/documentation,” but was not referenced by the MEB NARSUM examination.  The PT examination showed normal thoracolumbar ROM, except for decreased extension with muscle guarding and painful motion.  There was no abnormal gait due to muscle spasm or guarding and there was no abnormal spinal contour.  The therapist indicated there was “localized tenderness, muscle spasm, or guarding” from L1-L3.  

At the VA Compensation and Pension (C&P) examination on 10 November 2009, performed a month after separation, the CI reported the same back symptoms noted above.  Physical examination showed a normal gait, and LE strength, sensation, and reflexes were normal.  There was no spasm, guarding or tenderness noted.  There was full ROM without painful motion and the ROM was not additionally limited following repetitive use.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0% coded 5237 (lumbosacral strain).  The VA also rated the back condition 0% coded 5237, based on the VA C&P examination a month after separation, citing no evidence of limitation of motion, painful motion, muscle spasm, tenderness, or weakness.  The Board noted that at the CI had normal examination documented at the spine evaluation, MEB NARSUM examination and the C&P examination.  However, the Board agreed the total evidence in record supports a 10% rating and no higher based on tenderness, painful motion, and trigger points noted at intermittent evaluations in the STR and limitation of combined ROM at the MEB physical therapy examination, with tenderness and/or muscle guarding/spasm not severe enough to result in an abnormal gait or abnormal spinal contour.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  While the CI reported radiating LLE 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).”  There was no objective evidence of a radiculopathy with motor 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 recommends a disability rating of 10% for the back condition, coded 5237.  
BOARD FINDINGS:  In the matter of the back condition, the Board unanimously recommends a disability rating of 10%, coded 5237 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	
Low Back Pain	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140417, 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-2014-01702.

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