RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01694
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080822

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Network Intelligence Analyst, medically separated for “chronic low back pain [LBP] with radiculopathy,” with a disability rating of 10%.  

CI CONTENTION:  The CI continues to suffer from chronic back pain.  His 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 - 20080328	VARD – No VA Rating	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP with Radiculopathy	5243	10%	NA	NA	NA	NA	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Low Back Pain with Radiculopathy.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began as early as 2004, with no specific injury or trauma identified.  The MEB forwarded “chronic low back pain with radiculopathy” for PEB adjudication.  Radiographic studies (MRI) in May 2006 showed mild degenerative changes in the low back with a tear and small herniation of the disc at one level, with no impingement of the nerve root evident.  An evaluation in the emergency room on 21 October 2006 noted a normal neurological examination and normal range of motion (ROM) of the extremities (the back was not separately listed).  He was thought to have a neuropathy with a negative examination.  Evaluation by physical medicine and rehabilitation on 24 January 2007 noted a normal gait and full ROM of the lumbar spine.  The neurological examination was normal other than give-way weakness with ankle dorsi-flexion thought to be secondary to pain. He was diagnosed with lumbar neuritis (L5-S1) and non-surgical treatment was recommended. On 27 February 2007, in the family practice clinic, he was noted to have ongoing pain and painful motion. Motion was reduced, but lumbosacral (rather than thoracolumbar) ROM was recorded, reducing the value for rating.  Mild left hip flexion (L2) and dorsiflexion were noted.  Sensation and reflexes were normal as was the gait.  In the family practice clinic on 13 April 2007, the ROM was full in all planes as were sensation and the reflex examinations.  Motor function was reduced for external rotation of the left foot (L4-S2) and thigh flexion (L2).  The great toe flexion (L5) was normal.  The neurological examination was intact.  In physical therapy on 31 May 2007, the CI was noted to have reduced flexion and left lateral flexion and rotation.  Formal ROM testing was done on 7 November 2007 in physical therapy.  Active flexion was 65 degrees (rounded) and the combined ROM 175.  Of note, passive ROM was less in flexion at 45 degrees while the other measurements were similar to each other.  Three of seven signs of non-organic pain were present.  

The MEB NARSUM examination on 8 January 2008, 7 months prior to separation, noted complaints of persistent LBP with radiating pain and weakness.  The CI described leg weakness that caused him to need a handrail when walking up stairs.  The pain prevented lifting, or prolonged standing, and was caused by prolonged walking.  The pain was tolerable with sitting or lying down.  The CI reported that he was taking a nerve pain medication (pregabalin), morphine, and a non-steroidal anti-inflammatory drug (ibuprofen).  The physical examination showed a normal posture with no gross scoliosis (lateral bending of the spine), full ROM in all planes, with some tenderness of the back.  One test for nerve root impingement (straight leg raise [SLR]) was positive on the left side, while a confirmatory test (the flip test, or seated SLR) was negative bilaterally.  Testing for hip or sacro-iliac joint pathology was also positive on the left (FABER, or Patrick’s test).  Sensation was normal and reflexes of the lower extremities were 2/4 bilaterally.  Strength was 4/5 for external rotation of the left foot and left hip flexion, though the left big toe had “good strength.”  The Board noted that this examination was very similar to the entry dated 13 April 2007 by the same physician.  Despite conservative treatment including duty restrictions, medications, physical therapy, and injections, 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 an MEB.  The MEB forwarded “chronic low back pain” for PEB adjudication.  

The VA did not perform a Compensation and Pension (C&P) evaluation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic LBP with radiculopathy at 10%, coded 5243 (intervertebral disc syndrome [IVDS]), citing use of the VASRD.  No VA evaluation or rating was in evidence.  The Board considered the evidence.  It noted that while weakness was documented on a number of clinical entries, the muscles involved were not consistent from one examination to another and at least once the CI was thought to have reduced (apparent) strength due to pain.  Sensation and the reflexes were typically normal as was the gait.  However, weakness was documented on multiple examinations and a radiculopathy noted by the PEB.  The Board determined that the evidence does support the presence of an unfitting radiculopathy at separation and recommends a 10% rating for a mild paralysis of the sciatic nerve, coded 8520 (paralysis of the sciatic nerve).  

The Board then considered the rating for the LBP.  The ROM for active motion supports a 10% rating on the physical therapy examination.  The ROM for the passive flexion supports a 20% rating.  However, this examination is unusual in that the passive flexion is much less than active flexion without explanation.  The examination is also compromised by the presence of multiple signs of non-organic pain and it is also an outlier from other examinations with ROM (which are listed above).  The MEB NARSUM values mirror an earlier family practice examination, but are normal and the nearest measurements to separation.  Moreover, these are consistent with other measurements and the observed pathology.  In the 12 months prior to separation, there was no evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  The totality of evidence supports the 10% rating 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 chronic back pain condition, but recommends the addition of a separately unfitting radiculopathy at a 10% rating, coded 8520.  

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.  In the matter of the lumbar radiculopathy condition, the Board unanimously recommends that it be added as an additionally unfitting condition and a disability rating of 10%, coded 8520 IAW VASRD §4.124a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic LBP	5243	10%	
Lumbar radiculopathy	8520	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150628, 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-2015-01694.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR