RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01334
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20071029

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Crew Chief, medically separated for “low back pain,” with a disability rating of 20%.

CI CONTENTION:  The CI contends his back pain continues as well as dental issues.  The CI’s complete submission is at Exhibit A. 

SCOPE OF REVIEW:  The panel's scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the panel for Correction of Military Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’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 panel 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 panel 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 - 20071029	VARD 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LBP due to DDD with Radiculopathy	5243	20%	No VA Examination on file	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY: 

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 2005 without any specific injury or trauma.  The first record in evidence is a scoliosis survey (X-ray) dated 10 January 2006; it was normal.  The CI was thought to have muscle spasm and treated with medications, duty restrictions, and physical therapy (PT).  He was noted to have pain free and full range of motion (ROM) as well as a normal physical examination when seen in PT on 3 March 2006.  His pain was aggravated when he moved himself from one apartment to another in late March.  X-rays on 31 March 2006 showed disc space narrowing at L5-S1.  In orthopedics on 19 April 2006, he was again noted to have full ROM and a normal neurological examination.  Tenderness and spasm along the spine were absent.  He was tender over the sacroiliac joints though (between the pelvis and lower back).  Cross training was recommended.  An MRI on 3 October 2006 showed degenerative joint disease (DJD) at L5-S1 with some compromise of the outlets for the nerve roots at that level, left > right.  There was also degenerative disc disease (DDD) at the same level.  A nerve conduction study on 22 May 2007 was normal.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “low back pain” for PEB adjudication.  The MEB NARSUM examination was dated 28 June 2007, 4 months prior to separation.  The CI reported LBP which, since October 2006, radiated to his heels and toes.  He had been doing desk duty for the past 2 years.  The physical examination showed a normal back, discomfort with ROM with mild to moderate pain along with tenderness to palpation (TTP) and without muscle spasm.  Under the musculoskeletal examination, lower extremity strength was recorded at 4/5.  Under the neurological examination, the CI was noted to have “gross sensory and motor function normal.”  Gait was coordinated and even.  Reflexes were normal.  Under the back examination, the ROM was recorded as full with mild to moderate pain.  However, it was for the lumbar spine isolated rather than the thoraco-lumbar spine.  Flexion was 60 degrees (the VA normal 90 degrees is for the thoracolumbar spine; 60 is full ROM for the lumbar spine).  Extension and the lateral flexion were 25 degrees (VA normal are 30 degrees).  Rotation was not recorded.  As the thoracic spine accounts for this, it is not expected in measurements of the lumbar spine.  Gait and stance were normal.  Spasm was absent.  It was noted that the thoracic spine also had good ROM (as a rule of thumb, it contributes about 40% of thoracolumbar flexion).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, coded 5243 (intervertebral disc syndrome).  There was no VA rating since the CI did not file a VA claim.  The evidence does not support the presence of an unfitting radiculopathy at separation and an additional rating is not warranted.  The Board found no route to a rating higher than the 20% adjudicated by the PEB.  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 for the low back pain condition. 

BOARD FINDINGS:  In the matter of the low back pain 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 20150613, w/atchs
Exhibit B.  Service Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01334.

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