RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00933
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070730

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Vehicle Maintenance Journeyman, medically separated for “chronic low back pain, degenerative disc and facet disease,” with a disability rating of 10%.

CI CONTENTION:  His sleeping disorder and other injuries were not considered.  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 based on 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 - 20070518	VARD - 20080912	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain, Degenerative Disc and Facet Disease	5242	10%	Degenerative Changes L1-L2 and L2-L3 and Thoracic Scoliosis with Thoracic Strain	5242	10%	20080206	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Lumbar Spine.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was involved in a motor vehicle accident (MVA) in March 2002 sustaining multiple trauma.  There was an unverified report that this may have involved some direct lumbar spine and disc injury, but a consistent complaint of back pain did not surface in the STR until mid-2005 associated with complications of a left femur fracture from the MVA.  The leg pain improved with hardware removal, but the back pain then “became more apparent” (NARSUM).  Diagnostic imaging (MRI) at that time demonstrated degenerative disc disease (L4/5 and L5/S1, bulging with facet hypertrophy and “mild” foraminal encroachment on the right at L4/5).  There was no documentation in STR clinical entries of radicular symptoms, and there were numerous normal neurological examinations with none to the contrary.  Separate consultants (initial and second opinion) documented normal neurological examinations (5/5 strength all groups, intact sensation, symmetric reflexes) and opined that surgery was not indicated.  There was serial documentation in chiropractic notes of non-specific range of motion (ROM) limitation (grossly observed) that was variable but trending toward improvement.  The first neurosurgical consultant documented flexion to 90 degrees (normal) and extension to 15-20 degrees (normal 30).  There was no STR documentation of severe ROM limitation, gait disturbance, abnormal spinal contour, or incapacitating episodes.  A protracted trial of conservative treatment (including epidural steroid injections) did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for an MEB.  The MEB forwarded “chronic lower back pain” for PEB adjudication.  

The undated NARSUM examination documented persistent back pain (unquantified) with “no sensory/motor disturbances,” and specified functional limitations of “his duties as an auto mechanic ... [and] ... passing the physical fitness test.”  The physical examination recorded “mild” paraspinal tenderness and “decreased forward and lateral flexion.”  The examiner did not provide documentation of gait, spinal contour, or neurologic testing.  Formal ROM measurements for the MEB were conducted by physical therapy on 16 May 2007 (10 weeks before separation), and documented flexion to 65 degrees with combined ROM of 190 degrees (normal 240).

A VA Compensation and Pension (C&P) examination on 6 February 2008 (6 months after separation) documented “daily” daily back pain rated 5/10 and “occasional” sensory symptoms of the left leg that was aggravated by prolonged sitting or standing, lifting, and bending.  The VA examiner noted that CI was employed as a vehicle maintenance instructor and had not experienced any incapacitating episodes.  The physical examination recorded a normal gait and spinal contour, the absence of tenderness, and normal neurological findings with “5+/5+” strength, intact sensation, and symmetric reflexes.  Measured ROM was normal in all planes, specifying painful motion but no degradation with repetition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5242 (degenerative arthritis of the spine) was consistent with VASRD §4.71a criteria for the Service ROM and other ratable evidence.  The VA’s 10% rating under the same code cited the §4.71a 10% criterion for flexion, but members noted that application of VASRD §4.59 (painful motion) was necessary to support a minimum compensable rating based on the C&P evidence.  There was no ROM evidence supporting a rating higher than 10%, no evidence for abnormal gait or contour to support a 20% rating, no evidence for ratable peripheral nerve impairment that would provide for additional rating, and no documentation of incapacitating episodes or diagnosis of intervertebral disc syndrome that would provide for a higher rating under that formula.  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 PEB adjudication of the lumbar spine condition.    

BOARD FINDINGS:  In the matter of the lumbar spine 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.  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 20150606, 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 XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00933.

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,

XXXXXXXXXXXXXXXXXXXXX

Attachment:
Record of Proceedings