RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02571
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20080321

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Security Forces Craftsman, medically separated for “low back pain” with a disability rating of 10%.  

CI CONTENTION:  “I do not feel my case was fair.  I was involuntarily separated for back related issues (specifying bilateral leg pain) that continue to worsen.  I was rated VA 60% but nothing from the Air Force seems unfit.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20080128	VARD - 20081002	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5243	10%	Lumbar Degenerative Disc Disease 	5242	40%	20080813	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered an onset of low back pain with lifting in 2005.  It was initially intermittent but grew progressively worse over time.  There was intermittent bilateral lower extremity (BLE) radiation, rare sensory complaints and no subjective weakness.  Imaging demonstrated mild degenerative disc disease at L1-2 and L5-S1 without neural impingement.  Multiple normal neurological examinations (motor, sensory and reflexes) were documented in STR clinical entries throughout the clinical course, with no contrary findings.  

There were multiple STR entries that documented grossly normal range of motion (ROM), although some noted non-specific ROM limitation, and many noted painful motion.  There was no STR evidence for any significant ROM limitation.  There were numerous entries that documented a normal gait with no contrary findings.  A few entries noted abnormal spinal contour with evidence for congenital scoliosis, but none of these were correlated with spasm or guarding and most entries recorded normal curvature.  There was no evidence in the STR documentation of incapacitating episodes.

The 26 July 2007 MEB NARSUM examination, 8 months prior to separation, documented non-specific low back pain with proximal BLE radiation, but did not elaborate functional limitations.  The profile permitted walking at own pace, limited lifting to 20 pounds and standing to 20 minutes.  The physical examination recorded “ROM limited by pain” in all planes.  There were normal reflexes, without comment regarding other ratable findings.  Goniometric ROM measurements for the MEB were conducted by physical therapy (PT) 5 days later (31 July) and documented flexion to 90 degrees (normal) with a combined ROM of 225 degrees (normal 240) without addressing painful motion.

An orthopedic note on 2 January 2008, documented flexion to 80 degrees and extension to 15 degrees (normal 30).  A pain management consultant on 18 March 2008 documented flexion of “fingertips to distal shins” (normal or nearly so) with normal ROM in other planes and normal neurological findings.  The examiner advised against surgery and opined “most of the pain appears to be muscular in nature.”

At the 13 August 2008 VA Compensation and Pension (C&P) evaluation, 5 months after separation, there was no documentation of interim injury or other exacerbation of the condition.  The CI reported constant pain with BLE radiation of “moderate” severity that was aggravated by bending, lifting or prolonged sitting or standing.  The physical examination recorded a normal gait and spinal contour without tenderness, spasm or guarding.  Neurological findings (motor, sensory and reflexes) were normal.  The recorded ROM measurements reflected severe limitations with flexion limited to 30 degrees and combined ROM of 130 degrees.  Of note, the examiner reported the onset of pain for each plane at the point of the measurement itself, and noted that there was no further ROM limitation with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5243 (intervertebral disc syndrome), without citing a rationale; but, its rating was consistent with VASRD §4.71a criteria for the service evidence.  The PEB also addressed the CI’s contended rating for “bilateral sciatic neuralgia,” opining that it found “no clinical evidence that would indicate permanent nerve damage/neuropathy [and therefore] this condition is neither unfitting nor ratable.”  The VA rated the back condition 40%, coded 5242 (degenerative arthritis of the spine), referencing the C&P ROM evidence as satisfying the applicable criterion.  The VA did not confer additional rating for associated neuropathy, stating, “no neurologic impairment was objectively found.”

There was no evidence for abnormal gait or spinal contour to justify a 20% rating on that basis.  There was no evidence for incapacitating episodes for a favorable rating based on that formula.  There was conflicting ROM evidence, however, with all of the service ROM evidence supporting a 10% rating and the C&P evidence supporting a 40% rating.  The panel deliberated the probative value of this contradictory ROM evidence and noted the great preponderance of it was aligned with the Service PT ROM measurements.  The panel concluded the PT ROM carried the determinant probative value for its recommendation.  There was no logical clinical explanation for the severe ROM limitation reflected in the C&P examination, nor was such severe limitation consistent with the overall clinical acuity.  Furthermore, the C&P measurements were not consistent with the objective absence of spasm, tenderness and abnormal contour.  Additionally, the C&P examiner’s documentation raised a question of whether the recorded ROM reflected the subjective pain threshold rather than objective ROM excursion.  Therefore, the panel agreed that a 10% rating, but no higher, was justified for flexion greater than 60 degrees but not greater than 85 degrees, and/or combined ROM greater than 120 degrees but not greater than 235 degrees, as reported in the PT examination and corroborated by multiple Service examiners.  

Members considered whether additional rating could be recommended for the associated sciatic neuropathies, given that separate functional impairment linked to fitness is required to support such a recommendation.  The pain component of a radiculopathy is subsumed under the general rating as specified in the §4.71a spine formula.  There was no objective motor or sensory impairment that would be consequential to function or satisfy any compensable rating criterion.  Members thus agreed that additional service rating for the associated neuropathies could not be justified.  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 of 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 20170220, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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-2017-02571.

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