RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00035
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20061030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Security Forces Journeyman, medically separated for “chronic low back pain” with a disability rating of 0%.  

CI CONTENTION:  “I received only one appointment for evaluation/determination.  There were no follow up appointment nor course of treatment.  Classifications of rating was merely pain.”  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 - 20060918	VARD - 20070525	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	0%	Back Pain	5242	NSC	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in March 2005 while deployed and without any specific injury or trauma.  It was not relieved by nonsteroidal anti-inflammatory drugs (NSAID) or duty restrictions.  

At a family practice visit on 13 April 2005, the CI reported experiencing upper back pain over the previous month.  Physical examination revealed full, active range of motion (ROM) with mild pain while bending to touch her toes, and tenderness on the left and in line with the T4 vertebra; treatment consisted of a new NSAID and oral steroid.  Thoracic spine X-rays on 21 April 2005 showed no vertebral body compression, narrowed interspaces, or degenerative changes.  

At a 24 May 2005 primary care appointment, the CI complained of back pain radiating down the arms for the previous 3½ months.  The examiner assessed lumbar and thoracic back pain and recommended continued physical therapy.  During a 6 June 2005 follow-up visit, she reported continued upper back pain radiating to the lower spine, and on 15 August 2005, she endorsed upper back pain that radiated to her left arm.  MRI studies ordered for back pain and left arm parasthesias on 15 August 2005 were unremarkable with no indication of acute disease. 

During a 21 February 2006 family practice visit, the CI reported upper back pain between the shoulder blades since March 2005, and lower back pain for 6 months.  Physical examination revealed a normal gait and stance, and no tenderness.  The examiner opined that she had overuse symptoms likely related to performing her military duties.

A 16 May 2006 pain management evaluation noted CI complaints of back, left arm and left leg pain with muscle spasms in the legs and sensations of weakness in the back and left leg.  On examination, she transitioned from the examination table without difficulty and was able to heel-toe walk and squat.  Straight leg raise (SLR) (to determine nerve root irritation) and Patrick’s (to determine hip pathology) tests were negative.  The neck was supple and the back without abnormal scoliosis, kyphosis, or lordosis.  There was paraspinal muscle tenderness over the cervical area bilaterally and thoracic area on the left, but no appreciable spasms or trigger pints.  Cervical ROM was unremarkable and lumbar ROM revealed flexion to 90 degrees without discomfort.  There was no lumbar, sacroiliac, or gluteal tenderness.  The examiner was unclear of the etiology of the CI’s symptoms but opined that a principal component was myofascial, and recommend physical therapy, a neurology evaluation, possible use of a transcutaneous electrical nerve stimulation unit, anti-inflammatory medications, and enrollment in a tobacco cessation program.  At a 17 May 2006 primary care visit, the CI reported upper back pain that radiated to the lower back and left side of the body.  The examiner noted all treatment had failed to relieve symptoms and recommend follow-up with neurosurgery.  

Physical therapy thoracolumbar ROM measurements for the MEB on 4 August 2006, 2 months prior to separation, showed active flexion to 95 degrees (normal 90) and a combined ROM of 240 degrees (normal) with mild discomfort during lateral flexion at the end-range.  The 10 August 2006 MEB NARSUM examination, noted CI complaints of sharp, mid- and upper-back pain that radiated to the lower back.  Physical examination showed her to be in no acute distress with a normal gait and upper/lower extremity muscular strength and sensation.  Thoracic and cervical spine MRIs on 15 August 2005 were unremarkable.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 0%, coded 5237 (lumbosacral strain).  Panel members agreed 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, as the MEB NARSUM did not note the presence of painful motion, muscle spasm, guarding or localized tenderness.  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.  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 chronic low back pain condition.  

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.  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 20161208, 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 XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-00035.

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