RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00523
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard E7, Material Management, medically separated for “chronic low back pain, status-post diskectomy of L5-S1, with radicular pain and paresthesias" with a disability rating of 20%.  

CI CONTENTION:  The CI requested a review of all conditions.  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 - 20070302	VARD - 20081105	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain, Status-Post Diskectomy of L5-S1, with Radicular Pain and Paresthesias	5243	20%	Chronic Muscular Strain Superimposed on Postoperative and Degenerative Instability, with Surgical Scar	5237-5242	20%	20071024	
			L5-S 1 Radiculopathy, Left Lower Extremity Associated with Chronic Muscular Strain…	8599-8520	10%	20071024	
			Groin Pain…	7599-7525	NSC	20071024	
			Bilateral Upper Extremity Pain…   	8599-8515	NSC	20071024	
			Right Foot Pain…	8599-8520	NSC	20071024	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain Status Post Discectomy of L5-S1, with Radicular Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had his first back surgery in September 2003.  Following surgery, he continued to have pain and ultimately had his second back surgery, a revision of the first, on 2 May 2006.  Following the second procedure, he initially did well, but then had progression of the low back pain (LBP) and was not able to return to full duty.  In a primary care appointment on 19 October 2006, 6 months prior to separation, flexion was 50% of normal (45 degrees rather than 90) and extension was nearly normal but painful.  In orthopedics 2 weeks later, he was noted to have a restricted range of motion (ROM) of the lumbosacral spine, but to be neurologically intact.  

The MEB NARSUM examination, dated 11 December 2006 (4 months prior to separation) referred to the CI’s civilian records for the physical examination.  It was recommended that the CI be medically disqualified from further military service.  No comment was made on incapacitation.  On 18 April 2007, (12 days prior to separation) the CI was noted in primary care to have left foot and calf numbness as well as progressive LBP.  

At a primary care clinic visit on 9 October 2007, (5 months after separation), the CI reported ongoing LBP.  The examiner recommended continued physical therapy and stretching as well as weight loss.  Electrodiagnostic testing (EDX) on 15 October 2007, 6 months after separation, showed a moderately severe residual S1 defect of the left lower extremity (LLE).  

At the 23 October 2007, VA Compensation and Pension (C&P) evaluation, performed 6 months after separation, the CI reported numbness of the left calf and foot.  He was using an electrical stimulation unit with benefit.  On examination, there was a well healed scar.  The CI had forward flexion to “about” 10 to 15 degrees before it became uncomfortable.  The limit in motion was not recorded, only the onset of pain.  He was noted to have a ‘regular’ (normal) gait and normal stance (posture).  He was noted to be protective of back motion.  The panel observed that a limitation of flexion to 15 degrees is not consistent with a normal gait and that this limitation is consistent with the onset of pain rather a limitation in motion.  He could stand on his heels and toes.  Tandem gait was poor though.  The motor examination was normal without evidence of atrophy.  Sensation was reduced on the LLE as was the heel reflex.  He was thought to have L5-S1 radicular pain with a (sensory) radiculopathy.  

The VA spine C&P evaluation was performed the next day.  The CI reported ongoing LBP which radiated to both thighs, left greater than right.  The physical exam showed CI able to rise on toes and heels.  Forward flexion showed CI able to reach his tibia (the shin bone, 45 degrees or greater).  It was also noted that back motion showed flexion of 30 degrees (normal 90), extension 5 degrees (normal 30), rotation 5 degrees on the left and right (normal 30), lateral bending was 10 degrees and 5 degrees (normal 30).  In the sitting position, rotation improved to 25 degrees and 20 degrees.  It was not recorded if the flexion was thoracolumbar, lumbar, or lumbosacral.  The ability of the CI was able to bend to at least the lower portion of the knees is not consistent with a limitation in thoracolumbar flexion to 30 degrees.  Accordingly, the probative value of these measurements is reduced.  Moderate pain with motion was present.  Tenderness and spasm were noted.  Reflexes were normal at the knees and absent at the left ankle.  Sensation was decreased, laterally, at the left lower leg and foot.  Extension muscles were “very good” to left lower leg and foot.  No comment was made on strength otherwise.  The left calf was ½ inch smaller in circumference that the right; the medical officer noted that this is within normal variation.  A limp noted on the left foot, but the etiology was not recorded.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back condition 20%, coded 5243 (intervertebral disc syndrome), noting radicular pain and paresthesias (abnormal sensations).  The VA rated the chronic low back condition 20%, coded 5237-5242 (degenerative arthritis of the spine), citing decreased range of motion.  The VA also rated a radicular left leg condition 10%, coded 8599-8520 (sciatic nerve, paralysis, incomplete mild), citing incomplete paralysis below the knee as ‘mild’.  Both were based on the C&P examinations 6 months after separation.  The VA specifically noted that the ROM was reduced by an injury on 24 June 2005 and increased the ROM used for rating purposes in accordance with the recommendations of the examiner for the C&P evaluation in 2008.  The panel considered the evidence.  There was a paucity of ROM measurements for use in adjudicating this case.  Six months prior to separation, the CI was noted to have flexion which was 50% of normal (45 degrees) in a primary care appointment.  No ROM measurements were found in evidence at the time of separation.  Six months after separation, the initial C&P evaluation noted the onset of pain at 10-15 degrees flexion, but did not record the actual limitation in motion.  The next day, the CI was noted to be able to flex to at least his lower knees, but the actual measurements taken later in the examination were limited to 30 degrees flexion.  However, it was not recorded if this was thoracolumbar, lumbar, or lumbosacral motion.  The medical officer observed that a lumbar or lumbosacral flexion of 30 degrees is consistent with the 45 degrees or greater of (thoracolumbar) flexion implied by motion to the shins which was noted by the same examiner.  Two of the three examinations support flexion of 45 degrees or more.  One noted flexion limited to 30 degrees, but the probative value is reduced by the failure of the examiner to record what was actually being measured.  The panel concluded that the preponderance of evidence supported a determination that flexion was 45 degrees or greater.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the VA examination.  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.  The panel additionally noted numbness and decreased appreciation of vibration, light tough and pinprick to the lateral aspect of the left lower extremity.  A left leg limp was reported, but attributed to either pain or numbness; the former is subsumed under the rating for the LBP.  Other examinations noted a normal gait.  The motor examination was typically recorded as normal.  The panel determined that the evidence did not support a finding that an unfitting radiculopathy was present at separation and, therefore, no additional rating is recommended.

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 20160825, 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-2016-00523.

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