RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02334
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150519
SEPARATION DATE:  20050515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Information Management Apprentice) medically separated for low back pain.  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 temporary L4 and referred for a Medical Evaluation Board (MEB).  The “low back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “low back pain” as unfitting, rated 10%, citing application of the Department of Defense Instruction (DoDI) 1332.39/Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition(s) were determined to be Category II, (right hand pain) and Category III, (tobacco habituation & history of adjustment disorder).  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:  

IPEB – Dated 20050502	VA* - (~6 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Lumbar Strain (claimed as spinal disease)	5237	10%	20051130	
Right Hand Pain	8715-8799	CAT II	Right (Dominant) Carpal Tunnel Syndrome Associated
with Right Ganglion Cyst	8715	10%	20051130	
			Tender Scar, Status Post Right Ganglion Cyst Removal	7804	10%	20051130	
			Right Ganglion Cyst	5099-5024	0%	20051130	
Tobacco Habituation	CAT III	Not Addressed	
History of Adjustment Disorder	CAT III	Not Addressed	
Other x 0 (Not In Scope)	Other x 4 (Not in Scope)	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20061130 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Low Back Pain.  The narrative summary (NARSUM) dated 26 March 2005 (approximately 2 months prior to separation) noted the CI had onset of low back pain (LBP) following epidural anesthesia for labor in February 2004.  Imaging (MRI) showed a disc protrusion and nerve outlet narrowing of the left lower spine (L5-S1).  Neurologist and pain specialist evaluations (including electrodiagnostic testing EMG/NCV and dermatomal testing) indicated that LBP symptoms were not aligned with the spine pathology.  The CI’s LBP was unresponsive to therapy including profile restrictions, hospital admission (February 2005), multiple treatment and emergency room evaluations, and convalescent leave.  The CI was taking narcotic and non-narcotic pain medication and Neurontin (a nerve stabilizing medicine).  The NARSUM physical exam noted the CI was only comfortable standing, and was in pain with any movement of her back greater than 20 degrees.  Her back was diffusely tender in the paraspinal areas, lumbar spine and sacroiliac joints.  Neurologic evaluation in April 2005 (after the NARSUM) indicated the CI complained of pain, numbness and tingling in both feet and lower extremities.  Exam showed 4/5 weakness of the muscles of the upper foot (extensor digitorum brevis muscle that helps extend the toes).  Sensory examination showed decreased pinprick sensation in her left lateral leg and decreased light touch noted in her right big toe and left lateral leg.  The examiner indicated there was no abnormal gait, but she had “difficulty walking on her heals and some difficulty noted on tandem walking.”  Repeat EMG documented “chronic neurogenic changes which can be consistent with a left chronic LSS1 radiculopathy.”  

At the VA Compensation and Pension (C&P) exam performed 6 months after separation, the CI reported constant back pain of 7-10/10, up to 10/10 each day, and inability to lift over 10 pounds or walk longer than 5 minutes.  She had no radicular complaints.  The CI had a normal gait and there was spine tenderness and muscle spasm.  Goniometric range-of-motion (ROM) was with pain on all motions and forward flexion of 70 degrees (normal 90) with combined ROM at least 140 degrees (normal 240).  The examiner opined that there was an additional 5 degree loss of motion on repetition or flares due to pain.  Straight leg raise was negative and lower extremity muscle and neurologic testing was normal.  

The Board directed its attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated their exams at 10% coded 5237 (lumbosacral strain).  There were no goniometric ROM test results in the service treatment records and the PEB rating aligned with the NARSUM assessment that the CI’s LBP symptoms did not correlate to the documented spine pathology and physical findings.  All exams in evidence documented painful motion IAW VASRD §4.59, and all exams documented decreased thoracolumbar ROM.  The VA exam was the only ratable ROM in evidence and documented that forward flexion was greater than 60 degrees and combined ROM greater than 120 degrees which would rate no higher than 10%.  There was no abnormal gait or abnormal spinal contour to warrant a 20% rating.  

The CI reported episodes of radiculopathy; the MRI and April 2005 abnormal EMG and exam indicating toe weakness were evidence of intervertebral disc syndrome.  The Board considered possible alternate rating under code 5243 (intervertebral disc syndrome) with application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes.  The hospitalized days and quarters (but not convalescent leave) were considered incapacitating episodes (physician prescribed bed rest), but there was insufficient documentation of at least 2 weeks of incapacitation for any rating higher than 10%.  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.  

The Board finally deliberated if additional disability was justified for peripheral nerve impairment.  The CI reported intermittent radiating pain numbness and tingling in the lower legs.  However, there was only a single exam documenting and slight toe muscle strength that was not persistent through the post-separation VA exam, and gait was normal.  Pain (whether or not it radiates), stiffness, or aching is rated under the general formula for the spine and was considered in the spine rating above.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  There was insufficient evidence in this case of functional impairment attributable to peripheral neuropathy that adversely impacted duty performance.  The Board therefore concluded that no peripheral nerve (radiculopathy) condition could be recommended for additional disability rating.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right hand (dominate) pain condition was not unfitting and that the tobacco habituation and history of adjustment disorder conditions were not unfitting and not compensable.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  

Right Hand Pain.  The NARSUM dated 26 March 2005 and record indicated that the CI had right-hand pain following removal of a ganglion cyst (May 2004).  In August 2004, the CI had continued complaints of pain, weakness and numbness.  Neurology exam noted give away weakness (related to pain versus muscle or nerve abnormality) and grip strength was 50 pounds (compared to 60 on the left).  There was “a nonanatomic distribution of numbness … from the mid forearm down.”  Nerve conduction testing in January 2005 showed mild abnormalities (increased latency/slowing in right median sensory nerve) that were possibly consistent with carpal tunnel syndrome.  MRI in March 2005 documented a recurrent ganglion cyst and neurology evaluation in April 2005 (after the NARSUM) documented normal strength and reflexes in the upper extremities.  The VA exam 6 months post separation gave a history of decreased grip strength with inability to lift anything with the right hand which had diffuse numbness and “feels dead.”  She could not type or write for any length of time and could not brush her hair.  Exam documented tender scar on the wrist with a tender mass beneath.  Handgrip was normal and light touch sensation was decreased.  Nerve irritation signs were positive (Tinel’s and Phalen’s).  The right-hand pain condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that the right-hand condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right hand condition and so no additional disability rating is recommended.  

Tobacco Habituation and History of Adjustment Disorder.  The contended tobacco habituation and history of adjustment disorder conditions were adjudged as not unfitting and not compensable by the PEB.  Adjustment disorder is a condition or circumstance not constituting a physical disability IAW DODI 1332.38, E5 (the PDBR may not address alternative mental health diagnoses), and tobacco habituation does not constitute a physical disability.  Neither condition is a condition which could be compensable in the disability evaluation system at the time of separation.  The Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the tobacco habituation and history of adjustment disorder conditions.  

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.  In the matter of the contended tobacco habituation and history of adjustment disorder conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting and not compensable.  In the matter of the contended right hand condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 20142334, 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-2014-02334.

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