RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01345
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20080919

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Aerospace Maintenance Craftsman, medically separated for “back pain,” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.” 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 - 20080116	VARD	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain	5237	10%	No VA examination in evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 	

ANALYSIS SUMMARY:  

Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition was initially treated in May 2006.  He reported right flank and abdominal pain radiating to the groin.  Electrodiagnostic studies were normal and magnetic resonance imaging of the thoracic spine in August 2006 showed degenerative disc changes of the thoracic spine with disc bulging at T11-T12.  The CI underwent a T11-12 laminectomy in February 2007 with incomplete resolution of his pain.  Despite treatment, the back pain 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 on 23 April 2008, 5 months prior to separation, noted complaints of chronic low back pain.  Physical examination showed a normal gait and stance with a normal posture.  Peripheral nerves were normal and no peripheral neuropathy noted.  Thoracolumbar range of motion (ROM) was full with painful motion.  Strength, sensation, and reflexes were normal.  Physical therapy ROM for the MEB NARSUM showed a normal flexion of 90 degrees and combined ROM of 220 degrees (normal 240).  

The physical therapy examination on 18 June 2008, 3 months prior to separation, noted complaints of mid-back pain without motor or sensory disturbances.  Physical examination showed a normal gait and stance with a normal posture.  There was tenderness and muscle spasm on the right.  The ROM was flexion normal and extension with slight decrease due to pain.  Sensation was normal.  There was no VA Compensation and Pension (C&P) examination in evidence, the CI did not file a VA disability claim.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain condition 10%, coded 5237 (lumbosacral strain).  The Board agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) noted at the MEB NARSUM examination and tenderness, and muscle spasm noted on the physical therapy evaluation 3 months before separation which was not severe enough to cause an abnormal gait or abnormal spinal contour.  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 back pain condition.

BOARD FINDINGS:  In the matter of the 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 20150615, w/attachments
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-2015-01345.

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