RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00092
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20030905

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Supply Management Technician, medically separated for “chronic upper and lower back pain associated with degenerative disk disease” with a disability rating of 10%.  

CI CONTENTION:  The CI felt that her back and neck should have been separately rated.  The CI’s complete submission is Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 based upon a 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:  

SERVICE PEB - 20030625	VARD - 20040405	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Upper and Lower Back Pain…	5291	10%	Lumbosacral Strain…	5243	20%	20031107	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Upper and Lower Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s spinal condition began in 1999 after pushing a heavy weight.  Radiographic studies revealed degenerative disc disease (DDD) of the thoracic and lumbosacral spine.  Surgical intervention was not indicated.  Despite conservative treatment, to include medication and physical therapy (PT), the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred to an MEB.  The MEB forwarded “chronic lower and upper back pain” for PEB adjudication.  

At a primary care appointment on 4 April 2003, approximately 2 months prior to the MEB NARSUM, the CI reported continued LBP without radicular extension.  On examination, she demonstrated full range of motion (FROM).  Her gait, as well as neurosensory findings, was normal.  Tenderness was present about the muscles adjacent to the lumbar spine.  

At the MEB NARSUM examination performed approximately June 2003 (according to the time in Service dates) 3 months prior to separation, the CI reported “constant” upper and lower back pain (low > upper) with occasional pain extending into “…her thigh area.”  Her side of extended pain was not identified.  Physical examination (PE) indicated spinal ROM as “normal” as well as a “normal” gait.  Muscle strength, peripheral reflexes, and distal sensation were normal or intact.  Tenderness was present in the muscles adjacent to both the thoracic and lumbar spines.  

At the 7 November 2003 VA Compensation and Pension (C&P) examination, performed 2 months after separation, the CI reported a constant, dull, mid-lumbar back pain that worsened with increased activity.  She endorsed the inability to walk or run long distance.  Her PE revealed a normal gait and posture, although she had what appeared to be guarding: “very slow movement.”  There was decreased and painful motion of the lumbar spine noting forward flexion to 45 degrees (normal = 90) and extension to 20 degrees (normal = 30).  The spine was symmetric and tenderness was not present.  There was no comment with regards to the presence of muscle spasm and examination maneuvers for radicular signs were negative.  

The Board directed attention to its rating recommendation based on the above evidence. Although the PEB titled the back condition as upper and lower spinal components, Board members first agreed that the majority of clinical encounters contained within the case file referred more often to the low back as the primary condition and that the upper back was not considered a separate unfitting condition, but rather a subsumed condition under the low back pathology.  The PEB rated the back condition under VASRD interim spine rules at 10% coded 5291 (limitation of motion of the dorsal spine).  The VA rated the back condition under the new VASRD spine rating rules at 20% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination two months after separation, citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.  In accordance with DoDI 6040.44, the Board is required to recommend an impairment rating IAW the VASRD guidelines in effect at the time of separation.  

Board members acknowledged that the ROM values reported by the VA examiner, 2 months after separation, were significantly worse than those reported by both primary care and the MEB examiner 5 and 3 months before separation.  There was no recorded documentation of recurrent injury or adverse pathology in explanation of the more marked impairment reflected by the VA measurements.  While ROM limitations may progress over time, there was no evidence in the record from which to conclude that the severity at separation approached that portrayed by the VA measurement of 45 degrees of forward flexion.  Additionally, the para-spinal muscle tenderness that was present when ROM was normal (pre-separation) appeared to be absent with the single decreased ROM after separation as reported by the VA.  All Board members agreed that the MEB examination coupled with the primary care encounter as stated above remained more consistent with other STR documents and more reflective of the anticipated severity based on the condition’s clinical pathology.  Absent evidence of vertebral fracture (5285), ankylosis (5286, 5289), or significant spinal weakness (5294), the Board considered 2002 VASRD rating codes of either 5292 (lumbar; limitation of motion) or 5295 (lumbosacral strain).  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was no objective support for an impairment rating greater than the PEB’s current 10% and therefore, there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had symptoms of radiating pain documented in the treatment records; however, examinations indicated normal strength, reflexes, sensation and gait.  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.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  

BOARD FINDINGS:  In the matter of the back condition and IAW 2002 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.  The Board, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150102, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00092.

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