RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX	 CASE:  PD-2014-01935	
BRANCH OF SERVICE:  AIR FORCE 	 SEPARATION DATE:  20040730		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Medical Technician) medically separated for a low back condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a profile and referred for a Medical Evaluation Board (MEB).  The low back condition, characterized as “herniated disc, L5” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic low back pain (LBP) associated with herniated disc, L5” as unfitting, rated 10% referencing DoD and Veterans Affairs Schedule for Rating Disabilities (VASRD) guidelines.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Please consider all conditions.” 

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:  
   
Service IPEB – Dated 20040303	VA - (11.5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain associated with Herniated Disc, L5	5243	10%	Degenerative Disc Disease  (DDD) of the Lumbar Spine, Status Post Laminectomy with Radiculopathy, Sciatica to Right Lower Extremity	5242	20%	20050817	
Other x 0 (Not in Scope)	Other x 3 	20050817	
Combined:  10%	Combined:  50%	

ANALYSIS SUMMARY:  

Low Back Condition.  Absent direct trauma, the CI first developed LBP in basic training and was treated conservatively for a back strain to include physical therapy.  A magnetic resonance image revealed degenerative disc disease (DDD) as well as an L5-S1 disc bulge.  Having persistent symptoms, she received local and epidural steroids without prolonged pain relief.  She underwent spinal surgery (laminectomy and discectomy) in April 2004.  The case file did not contain post-operative treatment records, but did note that she was referred to a MEB.  At the MEB narrative summary examination (undated and presumed prior to MEB of 15 January 2004; at least 6 months prior to separation), the CI endorsed no additional symptoms.  The physical examination (PE) was brief and did not reveal any spinal tenderness.  No other examination parameters were documented.  

At the VA Compensation and Pension (C&P) examination (17 August 2005; performed 12 months after separation), the CI reported constant 3/10 pain to her low back and right hip associated with weakness and stiffness.  Additionally, she reported flare-ups of pain, spasms, and right radiculopathy while doing household chores.  Her PE noted decreased and painful motion of the thoracolumbar spine.  Additionally, there was lumbar tenderness and absent sensation on the right lateral thigh as well as the outside of the right foot.  The goniometric range-of-motion (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)	Neuro~8 Mo. Pre-Sep
(20031209) 	VA ~11 Mo. Post-Sep
(20050616) 	VA C&P ~12 Mo. Post-Sep
(20050817) 	
Flexion (90 Normal)	Back; Decreased ROM	Mild reduction of flexion, extension, and
rotation of the lumbar spine.	60	
Extension (30)			10	
R Lat Flexion (30)			10	
L Lat Flexion (30)			10	
R Rotation (30)			15	
L Rotation (30)			15	
Combined (240)	- 	-	120	
Comment	motor = ‘full strength’; 
‘good toe/heel walk’  	-	painful motion	
§4.71a Rating	non-ratable	non-ratable	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition at 10% utilizing code 5243 (Intervertebral disc syndrome) whereas the VA rated 20% under 5242 (degenerative arthritis).  Board members first agreed that the case file documents were insufficient in providing clinical evidence with regard to spinal motion prior to separation.  The single ratable parameters of spinal motion were not documented until 12 months after separation.  Having no known post-service additional pathology or trauma attributed to the CI’s back condition; Board members deliberated over the non-numeric verbiage utilized in prior exams as well as additional consultation evaluations contained in the case file.  Specifically, attention was focused on a requested psychiatric evaluation that was conducted due to the CI’s chief complaint of, "I can't live my life like this anymore. I want to be able to sleep and I want to stop checking things.”  After an extensive review of the recorded evidence, the Board majority concluded that the CI’s unrelenting chronic back pain condition which progressed with psychological overlay to a diagnosed “mood disorder with depressive features” equated to an impairment rating greater than the PEB’s 10%.  Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 20% for the chronic back pain condition. 

The Board additionally considered if the symptomatic lower right extremity radiculopathy warranted additional Service disability rating.  Although there was evidence of absent sensation on two described areas of the right leg and foot, the extent of the abnormality was not elaborated on nor did the description prove additional disability.  Board members concluded that the requisite link of altered sensation/neuropathy symptoms with functional impairment was not in evidence.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  

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 majority 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.  

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

UNFITTING CONDITION	VASRD CODE	RATING	
Lumbar Spine Condition	5243	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140424, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01935.

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