RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00355
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20041101

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

CI CONTENTION:  The VA gave him a higher rating.  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 - 20040823	VARD - 20050315	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	10%	Thoracolumbar Strain…	5003-5242	10%	20050112	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 2002 without specific injury or trauma.  Primary care visits for low back pain in January, April, and May 2003 recorded full range of motion (ROM) of the thoracolumbar spine without evidence of painful motion.  Magnetic resonance imaging in September 2003 showed no indication of disc herniation, spinal cord or nerve root compression, fracture or other pathology.  The STR documented 30 chiropractic visits for mid to lower back pain between May and October 2004.  The 17 July 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of back pain exacerbated by bending and lifting.  No physical examination was recorded.  

At the 12 January 2005 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported minimal symptoms since retirement.  He could walk ½ mile, denied use of assistive devices, and could carry out daily activities.  The physical examination showed a normal gait and spinal curvature, paraspinal muscle tenderness, and flexion to 90 degrees (normal) with some pain.  There was normal strength, sensation and reflexes, and no decreased ROM after repetition.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain).  The VA also rated the back condition 10%, analogously coded 5003-5242 (lumbar spine sprain), based on the VA C&P examination 2 months after separation, citing pain with extension.  Although painful motion was not recorded prior to separation, application of VASRD §4.59 (painful motion) was supported by consistent documentation of reported pain in the STR and at the post-separation C&P evaluation to achieve the minimum 10% rating under code 5237 (lumbosacral strain).  The panel agreed the 20% rating criteria were not met since lumbar flexion was normal with no reported muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for IVDS.  In addition, there was also no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  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 back 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 there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160531, 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-2016-00355.

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