RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04903
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20060221

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

CI CONTENTION:  “Condition was not properly evaluated at the time submitted to PEB.  Condition has since worsened due to incorrect treatment and evaluation.”  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 - 20051216	VARD - 20061120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low to Mid Back Pain 	5237	10%	Low Back Condition	5237	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Low to Mid Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in April 2004 after a fall.  Multiple physical therapy (PT) visits and medications (to include muscle relaxers and nonsteroidal anti-inflammatory medications) proved ineffective.  At the 15 June 2005 PT appointment, 8 months prior to separation, the examiner noted thoracic and lumbosacral spine tenderness, painful motion and full lumbosacral range of motion (ROM).  The family practice examination on 26 July 2005 documented lumbosacral paraspinal muscle spasm and tenderness, with a normal gait and full ROM.  On 19 August 2006, PT evaluation documented full lumbosacral ROM without exceptions and without painful motion.  

The 13 September 2005 MEB NARSUM examination, 5 months prior to separation, noted complaints of mid to low back pain.  Physical examination showed paraspinous tenderness and tight musculature bilaterally.  The examiner stated that the CI “had pain elicited with motion on previous exams;” X-rays showed no significant pathology to explain the cause of back pain.  At the family practice examination on 3 February 2006, the month of separation, the CI complained of chronic mid-and-low back pain with frequent back muscle spasm during prolonged activity and only fair pain control with medications.  Physical examination documented lumbosacral spine tenderness and tight paraspinal muscles.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain).  The VA rated the back conditions 0%, also coded 5237, based on the STR, citing a non-compensable evaluation.  Although there was insufficient limitation of motion to support a 10% rating, the panel agreed a 10% rating was justified for the presence of tenderness on the preponderance of examinations and evidence of painful motion.  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 back condition.  

BOARD FINDINGS:  In the matter of the low to mid back pain 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.  

XXXXXXXXXX
XXXXXXXXXX 
XXXXXXXXXX

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04903.

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,