RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03102
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20090629

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Security Forces Apprentice, medically separated for “low back pain…” with a disability rating of 10%.  

CI CONTENTION:   His condition continues to worsen and negatively impact daily activities.  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 - 20090302	VARD - 20090821	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LBP due to Grade II Spondylolithesis Associated w/ Spina Bifida Occulta at L5	5239	10%	Spondylolithesis and Stenosis of the Thoracolumbar Spine	5242	10%	20090128	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back Pain (LBP).  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s LBP condition began in January 2008 without history of trauma.  His back pain radiated into his left leg.  Radiographic and MRI imaging revealed degenerative changes with disc bulging and impingement on L5-S1 nerve roots.  An occult spina-bifida was present as well.  Despite treatment with physical therapy (PT), epidural steroid injections and a back brace, his painful symptoms remained.  Neurosurgery did not think the CI would benefit from surgery.  

The 2 December 2008 MEB NARSUM examination, 6 months prior to separation, noted complaints of dull achy LBP with sharp pain intermittently extending down into his left foot.  The physical examination (PE) revealed lumbosacral tenderness.  Spinal range of motion (ROM) was described as being “…able to flex to within 5 inches of touching floor with sharp pain at midline lower back.”  Extension was normal and non-painful.  Right and left rotation and side bending were “well tolerated.”  There was no associated muscle spasms or hip tenderness.  At the 28 January 2009 VA Compensation and Pension (C&P) examination, 5 months before separation, the CI reported constant stiffness, numbness, and sharp 8/10 pain of the low back that extended down the left leg.  Symptoms were exacerbated by physical activities and relieved by rest.  The CI endorsed the inability to stand or sit for prolonged periods.  His PE revealed decreased and painful ROM, noting flexion to 85 degrees (normal 90) and combined ROM of 195 degrees (normal 240).  After repetitive use, there was a 5 degree additional limitation of motion due to pain, fatigue, weakness, lack of endurance, and incoordination.  Additionally, there was evidence of radiation of pain, muscle spasms, and paraspinal muscle tenderness.  Curvature of the spine was within normal limits and there was no sensory deficit, motor weakness, or abnormal reflexes.  His gait was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5239 (spondylolisthesis or segmental instability), citing full lumbar ROM with tenderness.  Utilizing VASRD code 5242 (degenerative arthritis of the spine), the VA also rated the low back condition 10%, based on the C&P examination, citing forward flexion of the spine greater than 60 degrees but not greater than 85 degrees.  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) 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.  After due deliberation, considering all 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 low back condition.  

BOARD FINDINGS:  In the matter of the low back pain 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 20170327, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03102.

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