RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00954
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20040514

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

CI CONTENTION:  The CI made no specific contention.  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 - 20040315	VARD - 20041102	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	DJD of Thoracolumbar Spine	5010-5237	10%	20041018	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a history of chronic LBP, which was exacerbated in February 2000 after a fall.  There was no surgical indication.  At the pain management clinic examination on 5 May 2003, 12 months prior to separation, the CI complained of aching pain in the back and legs.  Physical examination showed a normal gait, tenderness and normal range of motion (ROM) with pain on some movements.  The spine showed slight thoracolumbar scoliosis, but there was no report of muscle spasm or guarding.  The 31 December 2003 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic daily LBP that improved with movement.  Physical examination showed a normal gait.  Although there was no examination of the back, the STR contained many evaluations in the 12 months prior to separation that showed either painful motion or tenderness of the thoracolumbar spine.  
At the 18 October 2004 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported flares-ups provoked by sitting or standing for prolonged periods, but denied any loss of ROM from the flare-up.  The CI could walk for 1 hour and drive for 4 hours before the onset of pain but could not run.  ROM of the lumbar spine was 85 degrees of forward flexion (normal 90) and 225 degrees of combined motion (normal 240).  There was no additional loss of ROM due to pain or incoordination with repetitive motion testing.  The examiner noted slight kyphosis, but did not mention the presence of spasm.  

The panel directed attention to its 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%, dual coded 5010-5237 (arthritis due to trauma-lumbosacral strain), based on the C&P examination 5 months after separation, citing limitation of motion.

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees; or combined ROM greater than 120 degrees but not greater than 235 degrees; or tenderness.  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.  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 back 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.  Therefore, the panel 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 20160922, 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

XXXXXXXXXXXXXXXXXX

Dear Applicant:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00954.

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,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings