RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01005
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040806

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Tactical Air Command and Control, medically separated for low back pain with a disability rating of 10%.  

CI CONTENTION:  The CI contends that PTSD was not considered.  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 - 20040504	VARD – 20051005 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Chronic Lumbar Strain	5024-5237	10%	20050415 	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Low Back Pain (LBP).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in 2003 after a motor vehicle accident.  X-rays taken in late 2003 were suggestive of early degenerative disc disease (DDD) of the lower lumbar spine.  Despite medication, physical therapy (PT), and activity restrictions, the CI’s low back symptoms remained and he was referred for MEB.

The 16 December 2003 MEB NARSUM examination, 8 months prior to separation, noted complaints of pain, made worse with walking or standing greater than 15 minutes, lifting or slouching for extended periods in a vehicle.  “The pain is localized to the lumbar region without radiation.  No lower extremity weakness, numbness or tingling.  No incontinence.”  His physical examination (PE) revealed spasm about the muscles adjacent to the lower lumbar spine.  His gait was normal and his distal neuro-vascular status was intact.  Flexion of the lumbar spine was normal at 90 degrees.  There were no other directional components of spinal motion documented.  Maneuvers for radicular signs were negative.  An Orthopedic examination performed on 12 February 2004, 6 months prior to separation, noted the CI’s chief complaint as “low back pain with right leg pain.”  He endorsed a nearly constant throbbing sharp pain with spasms in his low back.  “He denies any problems with his bowel or bladder or any weakness in his legs.”  His detailed PE was normal excepting the presence of lumbar muscle spasms.  “He ambulates without any difficulty.”  Although not numerically documented, his spinal range of motion (ROM) was listed as, “He has good ROM of his spine in flexion, extension, and rotation.”  His diagnosis was noted as low back pain with right lower extremity radiculopathy.  There was no evidence within the STR of any electro-diagnostic studies being performed.  

At the 15 April 2005 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported constant aching low back pain, which could be elicited by physical activity.  His PE to include ROM was completely normal noting the absence of spinal tenderness or spinal muscle spasms.  “There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition at 10%, coded 5237 (lumbosacral strain), citing IAW DoD and VASRD guidelines The VA also rated the low back condition at 10%, coded analogously 5024-5237 (tenosynovitis-lumbosacral strain) citing pain on extension.  There was no limitation of thoracolumbar spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine.  Although there was pre-separation spasms of the lumbar spine, such findings did not result in an abnormal gait or abnormal spinal contour which could have indicated a higher rating.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height, nor was there evidence of additional functional loss that would impact functioning in the average civil occupation.  Lastly, although the CI complained of back pain extending into his right leg, there was no objective 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 low back condition.  

BOARD FINDINGS:  In the matter of the low 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 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 20160920, 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-2016-01005.

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,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings