RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02617
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150415
SEPARATION DATE:  20090327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Maintenance Scheduler) medically separated for coccydynia.  The coccydynia could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty but she was authorized to perform an alternate physical fitness test.  She was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  The “chronic pain secondary to closed fracture/dislocation of the coccyx,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic pain secondary to closed fracture/dislocation of the coccyx (coccydynia)” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Disability reason-Broken Tailbone (Coccyx). Injury was sustained in the LOD by a slip and fall accident on the ice while stationed at Elmendorf AFB, AK.  Fall led to additional spinal injuries (torn/bulging disc in the L4/L5) not annotated by military doctors.  Pain and suffering also led to onset of severe depression.  Complete spinal x-rays were not done at the time of discharge due to pregnancy.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20090206	VA* - Same Day as Separation Date 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain…(Coccydynia)	5299-5298	10%	Residual Coccydynia…	5299-5298	0%	20090327	
Other x 0 (Not In Scope)	Other x 1	
RATING:  10%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20091217 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Coccydynia.  The CI had a history of low back pain (LBP) dating back to 2000 which apparently had minimal impact on her duties.  On 12 March 2007, she slipped on ice and fell onto her buttocks.  Subsequent X-rays on 23 April 2007 revealed a dislocation of the coccyx (tailbone).  X-rays of the lumbar spine were normal.  At a neurology evaluation on 30 April 2007, she was noted to have a normal neurological examination with the exception of areas of abnormal sensation which did not follow the distribution for any particular nerve.  The neurologist speculated that this might be secondary to muscle spasm.  She was treated conservatively with medications, physical therapy (PT) and chiropractic therapy without adequate relief.  Repeat X-rays of the coccyx on 10 July 2007 and 2 August 2007 were unchanged.  A magnetic resonance imaging (MRI) on 21 August 2007 revealed a small disc protrusion at L5-S1 with a possible tear in the disc and degenerative disc disease (DDD) at L4-5.  The coccyx remained dislocated.  She continued conservative management with persistent pain.  On 19 September 2007, she had her first epidural steroid injection (ESI) in pain management with improvement in her symptoms.  It was repeated on 31 October 2007 with benefit again.  She subsequently underwent a S5 nerve root block on 27 November 2007 with resolution of her pain.  She then had radio-frequency ablation of the left and right S5 nerve roots on 15 and 16 January 2008, respectively.  This improved, but failed to resolve her pain and she requested separation on 27 February 2008 in a primary care appointment.  A memorandum for record on 22 May 2008 by the pain management physician noted that although she had benefited from treatment, she would most likely not be able to return to full physical activity and MEB was supported.  The CI had another ESI on 10 September 2008 of the lumbar region.  

At a chiropractic evaluation on 5 November 2008, she was noted to have reduced thoracic and lumbar flexion and rotation.  However, the next day in primary care, the lumbosacral range-of-motion (ROM) was noted to be normal as were her gait and stance.  Tenderness along the spinal muscles was absent.  While in the MEB process, the CI became pregnant which further increased her discomfort and also further restricted her ability to sit.  She had been placed on one pain medication with benefit, but stopped it secondary to the pregnancy.  The narrative summary was initially dated 17 June 2008 and updated on 13 November 2008.  On the initial examination she was noted to have normal movement of the extremities with full flexion and tightness with extension; she was without neurological impairment.  At the second examination, the tightness was not recorded and it remained normal otherwise.  At the initial VA Compensation and Pension (C&P) exam performed on the DOS, the CI reported that she was physically active, 7 months pregnant, and engaged in water aerobics twice a week.  Her gait and stance were normal for her stage of pregnancy.  The neurological examination was normal and the ROM limited as expected from the changes of pregnancy.  Following separation, the CI was seen in the primary care clinic on 24 August 2009 with back and left leg numbness following an injury (not specified) 2 days earlier.  Her examination was unremarkable, but no ROM or neurological examination was recorded.  An MRI on 29 September 2009 showed disc disease and tears at L4-5 and L5-S1 with facet disease as well.  A second VA C&P for the spine was performed on 1 December 2009, 8 months after separation and 3 months after the after separation re-injury.  She reported pain radiating down both legs to the feet, left worse than right.  The gait and neurological examinations were normal and atrophy absent.  She was diagnosed with a bilateral L5-S1 radiculopathy, apparently based on the symptoms.  Her ROM was limited to 25 degrees for flexion and 105 degrees of combined motion.  Spasm and tenderness were present.  No specific comment was made about the coccyx.

The Board directed its occydynia (tail bone pain) at 10% using the analogous code 5299-5298 (removal of the coccyx).  The VA used the same code, but rated the coccydynia condition at 0%.  The Board noted the VA rated the CI at 40% for DDD of the thoracolumbar spine (and 10% each for radiculopathy of the left and right lower extremities, presumably in accordance with the General Rating Formula for Diseases and Injuries of the Spine as stipulated).  The Board considered the evidence.  It observed that the coccyx, while part of the spine, is distinct from the thoracolumbar spine.  In compliance with the VASRD, the highest rating for the coccyx appropriately using the 5298 disability code is the 10% adjudicated by the PEB.  The Board considered other codes, but none more accurately described the unfitting condition.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the coccydynia condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the coccydynia condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131210, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

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

Dear XXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-02617.

	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,

XXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR