RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02535
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20021007

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Bomber Avionics Systems Apprentice, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  The CI contends that his back condition remains problematic and should have been rated higher than 10%.  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 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 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 determination 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(s) 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 - 20020730	VARD - 20040925	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5295	10%	Residuals, Status Post Lumbar Laminectomy…	5243	10%	20040826	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  IAW DoDI 6040.44, the panel is required to recommend a rating IAW the VASRD in effect at the time of separation.  The panel noted that the 2003 VASRD interim standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The panel must correlate the clinical data with the 2003 rating schedule; applicable diagnostic codes include: 5292 (limitation of lumbar spine motion); 5293 (intervertebral disc syndrome; based on incapacitating episodes); and 5295 (lumbosacral strain).  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery with discectomy and laminectomy in August 2001 at L4-L5 and L5-S1.  The CI enjoyed resolution of his symptoms for 3 months, but then aggravated his back at work.  The 4 March 2002 pain clinic examination, 7 months before separation, noted a normal gait and neurological examination.  The range of motion (ROM) was not quantified, but extension was noted to be painful.  

At the 12 April 2002 NARSUM examination, 6 months before separation, the CI reported that he could run, but that it was limited to 1 mile.  On examination he had a normal gait and neurological examination.  Tenderness was present, but spasm not recorded.  The ROM was not recorded.  

The 26 August 2004 VA Compensation and Pension (C&P) examination, almost 2 years after separation, the CI reported that he was involved in a motor vehicle accident in December 2002, 2 months after separation.  He was still able to walk 3-4 miles per week.  On examination, the gait was normal.  Motion was painful and limited in flexion by 5 degrees both to the left and right.  The neurological examination was normal.  Although the examination was equivocal regarding spinal contour (in one place it indicated curvature of the spine was normal and in another place it indicated that there was lumbar flattening), X-rays showed normal contour.  Incapacitation from the back condition was not found in the evidence available for review.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5295, noting that the CI volunteered to paint houses in his off-duty time.  The VA also rated the back condition 10%, coded 5243 (intervertebral disc syndrome), based on the C&P examination remote from separation.  The panel considered the evidence.  Painful motion in extension was documented in the pain clinic 7 months prior to separation.  Neither incapacitation nor limitation of motion was documented proximate to separation.  The panel found no route to a rating higher than the 10% adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel 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 chronic low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150622, 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-2015-02535.

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,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings