RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02544
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150409
SEPARATION DATE:  20031003

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Security Forces Apprentice) medically separated for low back pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Air Force Specialty or satisfy physical fitness standards.  She was issued a temporary P3/L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic low back pain (LBP)” 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 Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”  The CI also attached a two-page letter to her application.  Her complete submission is at Exhibit A.

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 20030717	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5295	10%	Lumbar Disc Disease	5243	10%	20040131	
Other x 0 (Not In Scope)	Other x 4 	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20040421 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Low Back Pain Condition.  The first record in evidence for the LBP condition was a family practice note, dated 17 February 2002.  The CI was noted to have a history of chronic LBP in an evaluation for fainting at work.  She again noted LBP at another evaluation for fainting on 4 September 2002.  On 29 January 2003, she reported a 2-year history of LBP (by dates, prior to accession) with full but painful range-of-motion (ROM).  Over the course of the next 5 months, she was seen frequently in the clinic and emergency room for her back pain.  At an 18 February 2003 physical therapy (PT) appointment, she reported that the symptoms began after falling down a hill while in training.  In primary care on 7 March 2003, she noted persistent pain despite non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, narcotics, and PT.  She was also treated in the mental health clinic for relaxation techniques and pain management.  In family practice on 25 March 2003, she was noted to have pain out of proportion to her examination and was painful to maneuvers not expected to cause pain.  A narcotic contract was recommended (an agreement to have only one provider prescribe controlled drugs to prevent drug abuse).  She was again seen in the emergency room on 7 April 2003 and noted to have pain with maneuvers not expected to cause pain (non-organic signs).  A magnetic resonance imaging on 16 April 2003 was significant for degeneration of the L5-S1 disc with mild central protrusion.  A physical medicine encounter the next day again documented non-organic signs of pain, give way weakness (not true weakness, but can be from pain), normal reflexes, abnormal sensation but in a non-anatomic pattern, and reduced ROM with 40 degrees flexion and 10 degrees extension.  A steroid injection was recommended and accomplished.  An emergency room visit 2 weeks later on 30 April 2003 documented normal sensation and reflexes with “low effort” on the motor examination.  At a family practice visit on 14 May 2003, the CI requested a stronger narcotic and had multiple signs of non-organic pain and an exaggerated pain response.  The CI was seen in neurosurgery on 20 May 2003 and noted to have decreased sensation in an L5 distribution, slight decreased strength in both lower extremities in all muscle groups tested, and intact reflexes.  Electrodiagnostic testing on 21 May 2003 was negative for signs of a radiculopathy or neuropathy.  The commander recommended cross-training into a less physically demanding field in the 12 June 2003 letter to the PEB.  The narrative summary (NARSUM) was dated 23 June 2003 and noted persistent pain despite treatment.  The neurological examination was normal; the spine was non-tender; and, the ROM full.

At the VA Compensation and Pension (C&P) spine examination performed on 31 January 2004, about 4 months after separation, the CI reported back pain since falling in basic training carrying a rucksack.  She subsequently re-injured it carrying heavy machinery.  She reported flares several times a week, but was off medications due to her recent delivery.  The neurological examination was normal, the ROM was normal other than for lateral bending which was reduced 5 degrees bilaterally, and she was in no acute distress.  She was not in pain at the time of the examination.  Her gait was noted to be normal on a general C&P performed the same day.  The CI was seen in orthopedics on 19 July 2004, just over 8 months after separation.  She reported constant pain which was aggravated by prolonged walking and by lifting her children; she also stated that it was not related to activity.  Her gait and reflexes were normal and she did not guard her back with position changes.  She had pain at the extremes of motion in all planes.  She was noted to have chronic LBP with a negative examination.  The goniometric 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)	Phys Med ~6 Mo. Pre-Sep	MEB ~3 Mo. Pre-Sep	
VA C&P ~4 Mo. Post-Sep
	
Flexion (90 Normal)	40	FROM	90	
Combined (240)	---		230	
Comment	Signs of non-organic pain	No tenderness.  Painful motion not recorded.	No pain with motion	
§4.71a Rating	20%	0%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the back at 10% using an old code, 5295 (lumbosacral strain), using the VASRD in effect at the time of the PEB.  The VA also rated the back at 10% using the current (new) VASRD and the code 5243 (intervertebral disc syndrome).  The Board used the current rules, which were in effect at separation, but noted that this provided no advantage to the CI.  The Board considered if an unfitting radiculopathy was present at separation, but noted that the neurological examination was normal for both the NARSUM and VA C&P evaluations.  The presence of an unfitting radiculopathy at separation is not supported by the evidence.  The ROM of the NARSUM examination supports a 0% rating and the VA C&P a 10% rating.  There was no abnormality of gait or contour secondary to spasm, guarding, or tenderness to support a 20% rating under any code applicable for the back.  Incapacitation was not documented.  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 back 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 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 20140519, 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-2014-02544.

	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