RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02390
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040607

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

CI CONTENTION:  “CI contends that the rating should be higher as he continues to have significant issues surrounding his injury.”  The 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 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 panel’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 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 - 20040409	VARD - 20051130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5203	10%	Back Condition with Right Shoulder Involvement…	5237	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Chronic Back Pain Diagnosis.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in April 2003 while assigned to Basic Military Training (BMT).  CI detailed the back pain onset was gradual with no identifying trauma or injury.  Pain was described as starting at the right scapular region radiating into the right arm and leg and worsening with activity.  During BMT, the CI was diagnosed with scoliosis (scoliosis survey accomplished).  X-ray on 27 August 2003, determined no significant abnormality.  Bone scan in December 2003 was negative for inflammatory process. Magnetic Resonance Imaging (MRI) on 25 February 2004, showed abnormal fluid collection within L3 vertebral body and disc bulge at L4-L5.  Despite physical therapy adjustments to realign the left lower rib, Chiropractic treatments, and anti-inflammatory medications, the CI continued to report pain seven out of ten and was referred for an MEB.  The 10 January 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of back pain, intensity seven out of ten.  Piroxicam (anti-inflammatory) was taken for pain.  No lower extremity weakness, no paresthesia, and no loss of bowel or bladder control were reported.  Physical examination showed no back malformation or visual defects, full range of motion, no vertebral tenderness, negative straight leg raise (test for underlying herniated disk), and gait was normal.  At the 29 January 2005 VA Compensation and Pension (C&P) evaluation, performed 7 months after separation, the CI reported constant sharp pain in his upper back between the shoulder blades.  Pain was also reported in the lower back and described as a sharp knife into his back at times.  Physical exam showed pain between the spinous processes and the right shoulder blade with muscular palpation.  Tenderness to palpation was noted in the mid lumbar region.  Flexion was 80 degrees (hands just above the ankles) (normal 90 degrees) with no fatigue or muscle weakness with repeat flexion.  CI was able tip to left/right, approximately 45 degrees without pain (normal 30 degrees).  Extension was approximately 45 degree (normal 30 degrees) with grinding sensation which did not inhibit or cause painful motion.  Turning upper back right/left was approximately 45 degrees (normal 30 degrees) from the plane of the pelvis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5203 (clavicle or scapula, impairment) citing inability to perform military duties.  The VA rated the back condition Not Service Connected (NSC) coded 5237 (lumbosacral or cervical strain), based service treatment records, citing insufficient evidence showing the back condition worsened as a result of service, or service connection.  There was no limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine, however the NARSUM examination noted the presence of painful motion and the VA examination noted the presence of localized tenderness as evidence of painful motion with functional loss (based on §4.59, §4.40 and §4.45).  The panel agreed that a rating of 10% was warranted, however the VASRD code used in this instance was inappropriate and should be corrected.  The more appropriate code should be 5237 (lumbosacral or cervical strain).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB rating for the back condition but coding should change to 5237.  

BOARD FINDINGS: In the matter of the back condition, the panel unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.59.  There are no other conditions within the panel’s scope of review for consideration.  The panel 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 Back Pain	5237	10%	
	COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150901, 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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-02390.

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.  The Board recommended no re-characterization or modification of your separation.

I 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.  I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings