RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX						            CASE:  PD-2014-02548
BRANCH OF SERVICE:  AIR FORCE  	SEPARATION DATE:  20090116  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Security Forces Journeyman) medically separated for a chronic low back pain condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a temporary profile and referred for a Medical Evaluation Board (MEB).  The “chronic lower back pain” condition 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 with two small circumferential protrusions at L4-5 and L5-S 1 with compression on dural sac,” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB (FPEB) which affirmed the PEB findings and rating, and was medically separated.  

CI CONTENTION:  Her condition continues to worsen and negatively impact her daily activities.  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:  

FPEB - Dated 20080925	VA* - (~26 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain 	5243	10%	Intervertebral Disc Syndrome	5243	20%	20110317	
			Bladder Dysfunction	7599-7512	60%	20110317	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 4	
RATING:  10%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20111129 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Chronic Low Back Pain Condition.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s back condition began in 2005 with painful back spasm after training activity.  Radiographic studies showed two small disc protrusions at L4-L5 and L5-S1 with compression on the dural sac.  The CI had no relief with conservative therapy and was not considered a surgical candidate.  The MEB NARSUM exam on 23 May 2008 (8 months prior to separation) noted complaints of chronic low back pain with intermittent muscle spasms and intermittent shooting right leg pain.  The CI was taking nonsteroidal anti-inflammatory and narcotic medications.  On examination the gait was normal.  The back appeared normal and there was no tenderness or spasm.  There was “Full range of motion with flexion, extension, and left and right lumbosacral spine rotation without pain.”  The straight leg test was negative (for radiating symptoms).  Reflexes were normal and symmetric.  The final diagnosis was herniated disc at L4-L5/L5-S1 causing low back pain.  The CI had range-of-motion (ROM) testing for the MEB performed by physical therapy (PT) on 20 June 2008 (7 months prior to separation).  The CI complained of back pain and had numbness that went down the right leg to the toes when lifting heavy items; “not there during normal daily activities.”  ROM was measured in two segments with lumbar active ROM from L1 with forward flexion of 70 degrees after repetition (normal 90), and side bending to 30 degrees (normal 30) with pain on motion.  Extension to 35 degrees (normal 30) was “with intense pain and buckle at knees.”  The CI was seen in clinic on 25 November 2008 (2 months prior to separation) for a separation physical with no musculoskeletal system complaints and exam which indicated “Back: Normal.”  

At the VA Compensation and Pension (C&P) neurologic examination on 17 March 2011, 26 months after separation) the CI reported back pain after a fall in 2005.  The CI complained of limitation in walking (50 yards) due to back pain with symptoms of spasms, decreased motion and paresthesia (abnormal sensations); and denied incapacitating episodes, stiffness, fatigue and numbness.  The CI denied bowel or bladder problems in relation to her low back or herniated disc conditions.  Examination noted normal gait and posture.  There was tenderness without spasm or guarding.  ROM was forward flexion of 45 degrees (normal 90) and combined 140 degrees (normal 240).  Testing for radiating symptoms (SLR and Lasegue’s) was negative.  There was no weakness and sensory testing (pin prick) and reflexes were normal.  The neurologic exam stated “There are signs of Lumbar Intervertebral Disc Syndrome.  The most likely peripheral nerve is the Sciatic Nerve.  The Intervertebral Disc Syndrome causes bladder dysfunction with pad needed 7 time(s) per day.  The Intervertebral Disc Syndrome does not cause any bowel dysfunction.  There are no non-organic physical signs.”  Exam addendum explained the disconnect between the initial denial of bladder symptoms and the neurologic exam as better CI understanding after the exam and discussion with the physician and confirmed that she had bladder dysfunction.  

The Board directed its attention to its rating recommendation based on the above evidence.  The FPEB assigned a 10% rating under 5243 code (intervertebral disc syndrome) citing back pain with normal ROM.  The VA assigned a 20% rating also using code 5243 citing the VA exam 26 months after separation with thoracolumbar forward flexion greater than 30 degrees but not greater than 60 degrees.  The VA also awarded a rating of 60% analogous to code 7512 (chronic cystitis) citing bladder dysfunction requiring the wearing of absorbent material which must be changed more than four times per day.  Both VA ratings were effective January 2011 (24 months after separation).  Although there were no complete goniometric ROM exams IAW VASRD §4.70 (inadequate examinations) all treatment notes and the NARSUM exam documented painful or pain limited thoracolumbar forward flexion.  Only one more remote note indicated forward flexion which was not greater than 60 degrees.  The preponderance of the evidence supported a 10% rating IAW VASRD §4.59 (painful motion) or the spine formula under VASRD §4.71a. for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined ROM greater than 120 degrees but not greater than 235 degrees.  

The Board considered whether additional rating could be recommended under a peripheral nerve code, as conferred by the VA (60% for bladder dysfunction).  There was no complaint or evidence of bladder dysfunction proximate to separation and the Board adjudged that the VA exam was not indicative of the CI’s disability picture proximate to separation.  Functional impairment linked to fitness is required to support a recommendation for addition of a peripheral nerve rating to disability in spine cases.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  There was no fixed motor or sensory impairment in this case that could be linked to significant functional consequence.  There is thus insufficient evidence of a separately ratable functional impairment (with fitness implications) from any potential non-pain radiculopathy; and, the Board cannot support a recommendation for an additional disability rating on this basis.  The Board concluded therefore that no peripheral nerve condition could be recommended for additional disability rating.  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 FPEB’s 10% adjudication for the low back pain 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 pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication, and no addition of any ratable peripheral nerve condition.  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 20140521, 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-2014-02548.

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,

Attachment:
Record of Proceedings