RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02204
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20061120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for “low back pain” with a disability rating of 0%.  

CI CONTENTION:  The CI contends for his lower back condition as well as two out of scope conditions.  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 - 20060828	VARD - 20070629	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	0%	Chronic Low Back Pain, with Slight Narrowing of L4-5 and
Radiographic Evidence of Slight Scoliosis	5237	10%	20070405	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began without specific trauma in July 2005 while running up a hill during physical training.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic back pain” for PEB adjudication.  The MEB NARSUM examination on 25 July 2006, 4 months prior to separation, noted complaints of recurrent episodes of low back pain and stiffness “making getting out of bed or motor vehicle difficult.”  The CI additionally reported carrying heavy loads such as weapons and body armor worsened the pain and stiffness.  The physical examination showed “normal” thoracolumbar spine range of motion (ROM) with no pain, weakness, spasm or radiculopathy on movement noted.  Gait was normal.  Radiologic studies revealed a “grossly normal” lumbar spine.  

At the 5 April 2007 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported “numbness and tingling traveling down the back of both legs for the past year.”  The CI also reported “stiffness” and trouble getting out of bed, cars, difficulty standing, and weakness with heavy lifting. He reported pain when moving.  The physical examination recorded ROM as 70 degrees flexion (90 normal), 20 degrees extension (30 normal), 20 degrees right and left lateral flexion(30 normal), and 25 degrees right and left lateral rotation (30 normal).  All ranges were with pain.  Gait was normal, there were no signs of intervertebral disc syndrome and neurological examination of the lower extremities was normal.  X-ray studies of the lumbar spine revealed joint narrowing and slight scoliosis.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain 0%, coded 5237 (Lumbosacral or cervical strain), citing Department of Defense and Veterans Administration Schedule for Rating Disabilities guidelines.  The VA rated the low back pain 10% coded 5237 (Lumbosacral or cervical strain), based on the VA C&P examination 4 months after separation, citing forward flexion of the thoracolumbar spine. Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of painful motion IAW VASRD §4.59.  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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the low back pain, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the low back pain, the Board majority recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  The single voter if dissent recommended no change and did not elect to submit a minority opinion.  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	
Low Back Pain	5299-5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150814, with attachments
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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-02204.

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.  The Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I 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.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.

							Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachments:
1. Directive
2. Record of Proceedings

cc:  SAF/MRBR