RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01645
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060911

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

CI CONTENTION:  The CI thought the disability compensation would be higher.  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 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 - 20060707	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain…	5243	10%	No VA Claim in Record	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Low Back Pain with Mild Degenerative Disc Disease and Paravertebral Tenderness Diagnosis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in May 2005.  Since that time, the CI has reported constant back pain that gets better and worse.  No specific trauma or injury was reported.  Radiographic studies showed disc space narrowing at L1-L2 and L2-L3 along with mild annular disc bulging at L2-L3 and L4-L5, but no disc herniation.  

At the time of the neurology clinic appointment on 26 March 2006, the CI report pain with ascending stairs, pain interfering with sleep, the right leg “giving out”, and numbness and tingling radiating anteriorly down the right leg.  The CI detailed that after 20 minutes of walking she develops paresthesia.  Physical examination showed straight leg raising unremarkable on both sides, the CI able to twist right and left, stretch to the right and left, arch backwards and bend forward without difficulty.  Some point tenderness was noted over the mid-lumbar spine to deep palpation.  Motor was 5/5 in all muscle group and the CI had no difficulty arising from a low chair. Gait was normal, reflexes normal, and sensation intact to pinprick at L1-S1.  

Nerve conductive studies of the right peroneal and tibial motor nerves, the right sural nerve, and the bilateral H reflexes were all within normal limits.  The neurology evaluation concluded there was no electrophysiological evidence of a lumbosacral radiculopathy or a sciatic neuropathy on the right.  The MEB forwarded “low back pain” for PEB adjudication.  

The MEB NARSUM examination on 11 May 2006, 4 months prior to separation, noted complaints of constant low back pain with sharp pains in the low back paraspinous area bilaterally, especially in the morning and afternoons.  The CI reported being unable to wear her flack vest due to the pain.  Occasional numbness and tingling in the anterolateral aspect of the right leg was reported.
Physical examination showed tenderness to palpation over the bilateral paraspinous muscles, negative bilateral straight leg raise, ankle and knee jerk of 2/4 bilaterally, and 5/5 motor strength.  There was no VA C&P examination in evidence. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5243 (intervertebral disc syndrome).  Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of tenderness.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional 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 recommend a change in the PEB adjudication for the back condition.    

BOARD FINDINGS: In the matter of the back 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 20150624, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01645.

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
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings