RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00522
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040818

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Information Management Apprentice, medically separated for “low back pain” (LBP), with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  The CI’s complete submission is at 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 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:  

SERVICE PEB - 20040719	VARD - 20051118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	10%	Chronic Back Condition	5237	NSC	N/A	
Chronic Headaches	8100-8199	Category II	Migraines	8100	NSC	N/A	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A*	
*Subsequent Statement of the Case dated 20070607 denied Service connection for both conditions.  No other VARDS in evidence.

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began on 2 December 2002, 6 weeks after accession, without any specific injury or trauma.  She was referred to orthopedics, which had no definitive explanation of her pain.  Magnetic resonance imaging (MRI) on 25 February 2003 showed minimal right lumbar curvature with mild loss of intervertebral disc height but without desiccation (a shrinkage of the disc indicative of pathology); the lumbar spine was normal otherwise.  She was noted to have scoliosis (an abnormal curvature of the spine) in the absence of spasm on clinical examination.  As noted in the record, this is consistent with a developmental rather than an acquired condition.  Radiographic Imaging on 8 January 2003 confirmed scoliosis with mild degenerative disc disease (DDD) of her lower lumbar spine.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded chronic back pain for PEB adjudication.  The MEB NARSUM was dated 25 February 2004, 6 months prior to separation, and accomplished by a neurologist.  The CI reported that her spine hurt.  Her LBP was noted to be refractory to treatment.  The range of motion (ROM) was not recorded, but the neurological examination and gait were normal.  The ROM was noted to be normal at multiple clinical appointments including a primary care appointment the day prior to separation.  A VA compensation and pension (C&P) examination proximate to separation was not accomplished.  

The Board directed attention to its rating recommendation based on the above evidence.  The Informal PEB rated the back condition 10% coded 5237 (lumbosacral strain).  The CI then appealed to the Formal PEB, which determined that since the member's condition began so soon after her entry onto active service, the 180-day rule applied, and that the member's condition has not been permanently aggravated by military service.  No rating was assigned.  The CI next appealed to the Secretary of the Air Force Personnel Council (SAFPC) which concluded there remained a reasonable uncertainty as to the actual date of origin of the member's medical condition.  With the presumption the member was fit when she first entered active military service, SAFPC upheld the decision of the Informal PEB.  The VA did not service-connect the condition.  

There was no evidence for incapacitation or limitation in motion to support a higher rating.  The scoliosis was developmental rather than from spasm or guarding (it was noted to be present in the absence of either).  The neurological examination was normal.  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve 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 support a rating higher than the rating adjudicated by the PEB.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the chronic headache condition was not unfitting.  The headache condition was not profiled or implicated in the commander’s statement.  Review of the records shows only a single visit solely due to the headaches, an emergency room visit 6 weeks prior to separation.  The other visits were for the LBP and headaches were noted as also present.  There was no performance-based evidence from the record that chronic headaches significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 chronic headache condition and so no additional disability rating is recommended.   

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended headache condition, the Board unanimously recommends no change from the PEB determination.  There were no other conditions within the Board’s scope of review for consideration.  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 20150602, 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-2015-00522.

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