RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02579
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150204
SEPARATION DATE:  20040517

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Air National Guard E-5 (Aerospace Maintenance Apprentice) medically separated for a lumbar spine condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued multiple temporary P4 profiles and eventually referred for a Medical Evaluation Board (MEB).  Lumbago and obesity conditions were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated his lumbar condition as unfitting, rated 10%, with application of the DoD and Veterans Affairs Schedule for Rating Disabilities (VASRD).  The obesity condition was determined to be Category III (not separately unfitting or compensable).  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 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:

IPEB – Dated 20040311	VA* (~3 Months Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	L4-L5 Herniation …	5242	20%	20040831	
Obesity	Cat III	No VA Placement	
Other x 0 (Not In Scope)	Other x 3	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050217 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Lumbar Spine Condition.  The CI first injured his back in August 2003 from a strain injury during a Guard deployment to Germany.  The initial entry in the available service treatment record (STR) is from 26 August 2003 (9 months prior to separation), documenting right-sided spasm with normal neurological findings and yielding a diagnosis of acute lumbar strain.  A physical therapy (PT) note from that same period records a 50% reduction in range-of-motion (ROM) due to pain.  There are multiple primary care and PT notes over the ensuing months which document normal strength (5/5) and neurological findings, and none to the contrary.  A normal gait is documented in some exams, and antalgic or listing gait in others.  Imaging (MRI) noted congenital stenosis (narrowed spinal canal), mild degenerative changes (spondylosis), and disc disease (L4/5 disc with left nerve root compression, and mild posterior herniation without neural compromise at L5/S1).  Neurosurgical consultation was obtained in November 2003 (6 months prior to separation).  The consultant documented the absence of subjective weakness or numbness, a normal gait, lumbar extension limited to 15 degrees (normal 30), grossly normal flexion, and detailed normal neurological findings; opining that surgery should be deferred.  The CI underwent a series of epidural injections with some (but inadequate) improvement.  There are no STR entries documenting abnormal spinal contour or periods of incapacitation.

The narrative summary (NARSUM) conducted on 22 January 2004 (4 months prior to separation), and did not elaborate the pain severity or limitations; stating only that “his back has not significantly improved,” but adding, “His physical exam is not consistent with the degree of pain he is describing.”  The physical exam noted gait disturbance (“favoring right side”) and paraspinal tenderness, with normal neurological findings.  The recorded ROM was “full flexion with pain at extreme (120 degrees), extension limited to 45 degrees,” and lateral flexions of 45 degrees each (normal 30), without measurements of rotation. A civilian PT entry from March 2004 (2 months prior to separation) documented ROM as “flexion 50%, extension 25%, sidebending right 100%, left 90%,” also noting “guarded” gait; and, the same examiner in May 2004 (2 weeks prior to separation) recorded flexion 75% (~ 70 degrees [normal 90]), extension 50%, and lateral flexions of 100% each (without comment regarding gait).

A VA outpatient note 2 months after separation documented abnormal gait and abnormal spinal contour, but another note a month later recorded a normal gait.  The VA Compensation and Pension (C&P) examination conducted on 31 August 2004 (3 + months after separation), and noted constant back pain “never less than 3 [out of 10] even with his medications”; further documenting “he does use a cane occasionally and he says on bad days he cannot walk very far at all.”  The physical exam documented a normal gait and elaborated a hypersensitivity to palpation and pain with “every movement that I had him do”; specifically referencing and corroborating the NARSUM examiner’s comment regarding the inconsistency of reported pain with the exam.  Neurological findings were normal (5/5 strength).  The ROM measurements were flexion 45 degrees commenting “he said he could not go any further due to pain,” extension 20 degrees, right lateral flexion 30, and left lateral flexion 20.  As with the NARSUM ROM measurements (and all ROM exams in the record), the VA examiner did not provide measurements for rotation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5237 (lumbosacral strain) is compliant with VASRD §4.71a criteria for the NARSUM ROM evidence (conceding painful motion), but did not apply the §4.71a criterion of abnormal gait for a 20% rating.  The VA’s rating under 5242 (degenerative arthritis of the spine) cited the §4.71a criterion of the C&P flexion to 45 degrees for a 20% rating.  It is noted that the NARSUM supernormal ROM values are clinically suspect (especially for an obese patient), and the probative value suffers somewhat in that regard; although, neither the VA nor exams were compliant with VASRD §4.46 (accurate measurement), omitting the required measurements of rotation for deriving combined ROM.  It is also noted that both the NARSUM and C&P examiners raised concerns with regard to the probative value of the ROM measurements and physical findings as affected by the CI’s pain reactions.  The Board therefore had to evaluate the total evidence with regard to the most probative assessment of ROM limitation and whether to apply the abnormal gait criterion for a 20% rating recommendation.

With regard to the ROM assessment, the probative value detraction of the NARSUM measurements, which were incongruent with clinical expectations, favors concession to the VA C&P ROM evidence.  The civilian PT evidence in the interval between the NARSUM and separation also indicates that the lack of ROM limitation suggested by the NARSUM measurements was not a fair reflection of the CI’s baseline ROM impairment.  Member consensus was therefore that the total evidence favors concession of the C&P ROM measurements as a basis for the Board’s rating recommendation.  With regard to the antalgic gait criterion, the STR, NARSUM, and after separation VA outpatient evidence confirm that antalgic gait was an intermittent, but consistent, finding.  Member consensus was therefore that the total evidence also favors concession of the antalgic gait criterion as a fair basis for the Board’s rating recommendation.  There was no evidence of ratable peripheral nerve impairment or documentation of incapacitating episodes in this case which would provide for additional or higher rating.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board’s majority consensus recommendation is a 20% rating for the lumbar spine condition; proposing code 5242 for its clinical compatibility.

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.  To the extent that DoD guidance may have been applied to the PEB rating, the case was adjudicated independently of any such direction by the Board.  In the matter of the lumbar spine condition, the Board majority recommends a disability rating of 20%, coded 5242, 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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Lumbar Disc Disease	5242	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140602, 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 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-02579.

	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,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachments:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR