RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03506
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for “chronic back pain…associated with anxiety disorder” with a disability rating of 10%.   

CI CONTENTION:  In addition to the back and anxiety conditions, her feet also should also have been found unfitting.  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 - 20050427	VARD - 20060823	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain… Associated with Anxiety Disorder 	5243	10%	Anxiety Disorder	9400	10%	20060210	
			Degenerative Disc Disease Thoracic & Lumbar Spine	5242	0%	20060214	
Bilateral Foot Pain	Cat II	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Back Pain… Associated with Anxiety Disorder.  The PEB combined the back condition and anxiety disorder under a single disability rating, coded 5243 (intervertebral disc syndrome), and rated 10%.  The panel noted that these are not conditions that can be readily combined under a single rating, but reflected the PEB’s judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  Therefore, the panel’s initial charge in this case was directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the back condition and anxiety disorder is considered separately, with attendant recommendations regarding separate fitness, and separate rating if indicated.  

Back Condition.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI began having intermittent, lower extremity paresthesias in January 2003 after jumping out of a vehicle in July 2002.  A thoracic spine MRI showed a T8-9 disc herniation, with slight pinching of the right anterior spinal cord; and compressed discs at T10-11 and T11-12.  Surgery was not recommended, but nerve cauterization was offered and declined.  The 31 March 2005 MEB NARSUM examination, 2 months prior to separation, noted CI complaints of chronic mid-back pain, and the inability to lift more than 10 pounds, run, or perform regular unit physical training.  Although she was unable to carry a weapon, it was because she was taking sedatives and not due to back pain.   The examiner noted midline T8-10 tenderness, but normal reflexes and motor strength.    Range of motion (ROM) testing showed flexion of 60 degrees (normal 90) and combined ROM of 165 degrees (normal 240).

At the 14 February 2006 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI reported intermittent mid and low back pain with left lower extremity radiation and associated numbness and tingling, but no weakness. Physical examination showed diffuse tenderness throughout the thoracic and lumbosacral spine.  Measure ROM showed flexion of 90 degrees and combined ROM of 240 degrees, with painful motion.  Gait and motor strength were normal, and there was no physician prescribed bed rest within the past 12 months.

The panel directed attention to its rating recommendation based on the above evidence.   As noted above, the PEB rated the bundled back and anxiety disorder 10%.  The VA rated the back condition 0%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing X-ray evidence of arthritis with normal ROM and no objective evidence of pain on motion. 

Panel members first considered if the back condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The back condition was profiled with duty-limiting restrictions, implicated in the commander’s statement as “affecting her ability to perform any of the duties associated with the security forces career field,” and the MEB NARSUM examiner noted the CI was unable to lift more than 10 pounds, run for any distance or perform physical training.  The panel agreed the evidence reasonably justified the functional limitations of the condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended for the back condition.  Panel members acknowledged the normal findings of the C&P examination, but agreed the NARSUM examination best represented the back condition at the time of separation.  The NARSUM recorded painful motion with flexion of 60 degrees and combined ROM of 165 degrees, and thus the panel adjudged that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the back condition, coded 5243.  

Anxiety Disorder.  According to the STR and MEB narrative summary, the CI requested a referral to mental health (MH) for pain management training after her back injury.  She participated in counseling, was not prescribed psychotropic medication, and did not require emergency treatment or hospitalization for her anxiety disorder.  In the 7 April 2005 MEB NARSUM MH addendum, the examiner stated that the CI was “socially active…with a good support network of both peers and family members” and “received rave reviews for her dedication and competence, despite her physical challenges.”  She had been offered a prescription for anxiety, but declined because of her desire to avoid additional medications.  The mental status examination (MSE) was unremarkable with the exception of mildly anxious mood and affect.  The examiner diagnosed anxiety disorder due to general medical condition and opined that “chronic nature” of the back injury had led to her “emotional struggle with anxiety” with a positive response unlikely “given the surrounding circumstances.”

The 10 February 2006 VA Compensation and Pension (C&P) MH examination, 8 months after separation, noted the CI was not taking psychotropic medication or receiving any MH treatment.  She was employed and attending college, and reported some lost time from work because of her back problem.  The MSE was unremarkable with the exception of anxious mood. The examiner diagnosed anxiety disorder due to general medical condition.

Although the anxiety disorder was temporarily profiled and forwarded by the MEB to the PEB for fitness adjudication, neither of the two commander statements implicated an MH disorder as limiting world-wide duty qualification, with the endorsement that her duty performance had “always been exemplary, despite the fact that she is often in great pain.”  

The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the anxiety disorder 10%, coded 9400 (generalized anxiety disorder), based on the C&P examination, citing some difficulty in social and occupational functioning.  Panel members first considered if the anxiety disorder, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The NARSUM addendum documented an unremarkable MSE, with the exception of mildly anxious mood and affect, and the examiner noted that the anxiety disorder was due to the quality of life changes caused by her back injury.  The CI had a temporary MH profile beginning in January 2005; however, no limitations were recorded in relation to an MH condition.  The commander’s statement indicated exemplary duty performance, despite her back pain.  The panel majority concluded the preponderance of evidence showed the anxiety disorder would not reasonably have caused the CI to be referred into the DES or be found unfit due to the condition, nor was there any MH condition documented by the MEB or VA examiners which would logically be associated with significant disability.

Contended PEB Condition:  Bilateral Foot Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not noted on limited duty forms or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  In the matter of the anxiety disorder, the panel majority agrees it cannot recommend it for additional disability rating.  The single voter for dissent did not elect to submit a minority opinion.  In the matter of the contended bilateral foot condition, the panel agrees it cannot recommend it for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Back Pain	5243	20%	

SAF/MRB
1500 West Perimeter Road, Suite 3700 Joint Base Andrews, MD 20762

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Dear XXXXXXXXXX:
Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03506.
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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities. Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay.
I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force. This will not result in any change to your separation documents or the amount of severance pay you are entitled to. Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.