RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  PD-2016-00680
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040820 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Air Transportation Journeyman, medically separated for “low back pain” with a disability rating of 10%.   

CI CONTENTION:  “Please review 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 - 20040630	VARD - 20041115	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Anterolisthesis, L5-S1	5237	10%	20041025	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Low Back Pain (LBP).  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in October 2002 with no history of direct trauma.  An MRI performed on 30 June 2003 revealed minimal anterior vertebral slippage of L5 on S1.  At the 30 October 2003 clinic visit the CI reported her back pain worsened with lifting, climbing stairs or prolonged standing and was relieved with rest.  On physical examination (PE), her lumbar spine had full range of motion (ROM) and her gait was normal.  

The 12 April 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of LBP with various intensities of pain.  Physical therapy and chiropractic care failed to provide any lasting benefit.  Her PE revealed a normal gait and no spinal tenderness or spasms.  She had full flexion of the thoracolumbar spine as evidenced by flexing at the waist and placing both hands flat on the floor.  

At the 25 October 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported constant LBP with weekly flare-ups to include pain radiating into her left leg.  Her PE did not reveal tenderness about the spine.  Her combined thoracolumbar ROM measured 235 degrees (normal 240).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5237 (lumbar spine strain).  Utilizing the same code, the VA also rated the back condition 10%, based on the C&P examination 2 months after separation, citing combined ROM of the thoracolumbar spine greater than 120 degrees but not greater that 235 degrees.  

The panel agreed that a 10% rating, but no higher, was justified for the combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the VA examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB.  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 adjudication for the LBP condition.

BOARD FINDINGS:  In the matter of the LBP 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160913, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

SAF/MRB

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00680.

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