RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00353
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20030714

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O4, Logistic Readiness, medically separated for “low back pain” with a disability rating of 20%.

CI CONTENTION:  The CI contends the back pain persist resulting in additional procedures and physical limitations.  The CI’s 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 FPEB - 20030425	VARD - 20031008	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5295	20%	Degenerative Arthritis S/P Surgery Lumbar Spine	5292	40%	20030821	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain Diagnosis.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 1988 while attending the Air Force Academy.  He was diagnosed with a herniated disc and underwent a partial L4-L5 discectomy.  In 2002, the CI underwent fusion surgery of L4-S1 that failed.  Electromyography study (EMG) on 17 April 2003, showed normal peripheral nerve conduction studies in the right upper and both lower extremities.

The MEB NARSUM examination, noted complaints of continued back pain poorly responsive to treatment.  Pain reported as daily and increased after stretching exercises with pain being worse in the morning and at the end of the day.  Physical examination showed decrease sensory in L4 distribution of the lower legs, inability to walk tip toe or on heels, and decreased deep tendon reflexes in knees and ankle.  Surgical scars were well healed.

At the 21 August 2003 VA Compensation and Pension (C&P) evaluation, performed 1 month after separation, the CI reported numbness in the feet, loss of strength, and back pain.  Physical examination showed pain on movement, presence of paraspinal muscle spasm, and tenderness at L4-L5.  Radiculopathy was absent.  Normal gait and posture present.  Upper and lower extremity sensory and motor function were normal.  Range of motion reflected flexion 10 degrees (normal 90 degrees), extension 10 degrees (normal 30 degrees), right lateral 20 degrees (normal 30), left lateral 20 degrees (normal 30 degrees), right rotation 35 degrees (normal 30 degrees) and left rotation 20 degrees (normal 30 degrees).

The panel directed attention to its rating recommendation based on the above evidence.  The FPEB [Formal Physical Evaluation Board] rated the back condition 20%, coded 5295 (lumbosacral strain), “based on his level of functionality.”  The FPEB noted the CI had continued working in his assigned duties but had not been able to work the long hours required.  He had no exercise program but had some limitations in the activities of daily living.  He had no difficulty with ambulation but was unable tolerate prolonged standing or sitting.  The panel considered the FPEB’s description of the CI condition at separation reflected a moderate disability.  The available STR supports the PEB’s findings.  The Panel also considered the VA examination most proximate to separation; however, was unable to find support for the higher rating based on the STR.  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 low back pain condition. 

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel 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 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 20160524, 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-2016-00353.

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,

Attachment:
Record of Proceedings