RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX  	CASE:  PD-2017-05376
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080505

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

CI CONTENTION: “Not all conditions … were taken into consideration. Continuous treatments and recommendations were not factored in.”  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 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 – 20080122 	VARD - 20091008	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Traumatic Thoracolumbar Spine Disease	5242	10%	20090724	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was involved in a motor vehicle accident (MVA) in January 2003.  He sustained no back injury in the MVA, but started to experience back pain in June 2003 while in technical school.  X-rays of the thoracic and lumbar spine in 2005, 2006 and 2007 were normal.  MRI performed in August 2005 revealed possible mild degenerative disc disease at L1-2.  In July 2006 he was referred to neurosurgery with the impression that he was not a surgical candidate.  

The 5 June 2007 MEB NARSUM examination, 11 months prior to separation, noted complaints of back pain that radiated into his buttocks at times.  Physical examination showed a normal gait and stance, and normal movement of all extremities.  Thoracolumbar range of motion (ROM) measurements (in degrees) performed by physical therapy (PT) on 11 June 2007 recorded active flexion to 65 (normal 90), extension 25 (normal 30), right lateral flexion 35 (normal 30), left lateral flexion 35.  

At the 24 July 2009 VA Compensation and Pension (C&P) examination, 14 months after separation, the CI reported constant moderate daily ache and pressure, with sharp radiation of pain to the left leg and buttock to the knee.  Physical examination showed no lumbosacral spine tenderness, and no muscle spasms.  There was normal gait and spinal contour.  Thoracolumbar ROM measurements showed flexion of 80 degrees and combined ROM of 225 degrees (normal 240).  There was no additional limitation after repetitive movement.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbar spine strain), citing accordance with Department of Defense and Veterans Administration Schedule for Rating Disabilities guidelines.  The VA also rated the low back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of the thoracolumbar 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 as reported on the NARSUM 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 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.  

 

SAF/MRB

Dear XXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-05376.

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 rating modification or re-characterization 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 modification of your disability rating or characterization of your separation is not warranted.  Accordingly, I accept the recommendation that your application be denied.