RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02720
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150422
SEPARATION DATE:  20070105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Financial Management and Comptroller Journeyman) medically separated for ankylosing spondylitis (AS).  The back could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued a temporary P4L2 profile and referred for a Medical Evaluation Board (MEB).  “Ankylosing spondylitis” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated “ankylosing spondylitis” as unfitting, rated 10% citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and DOD guidelines.  The CI made no appeals and was medically separated.

CI CONTENTION: The CI elaborated no specific contention in his application.

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:

Service IPEB – Dated 20061115	VA - (3 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Ankylosing Spondylitis	5240	10%	Ankylosing Spondylitis w/Radiculopathy and Esthesopathy 	5240-5002	40%	20061002	
Other x 0 (Not in Scope)	Other x 2	
Rating:  10%	Combined Rating:  50%	
Derived from VA Rating Decision (VARD) dated 20070501 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Ankylosing Spondylitis.  The CI had a history of low back pain (LBP) since 2001 which was initially treated with medications, physical therapy (PT) and injections.  He reported a history of AS and was diagnosed with this condition in 2003.  Due to his back pain, he was cross-trained from security forces into finance in 2003.  He did well over the next few years, but had recurrent LBP in the summer of 2006 which lead to reevaluation.  He was seen in rheumatology on 1 August 2006 and noted to have a reduced flexion of the lumbar spine of 4 cm, but without signs of active joint inflammation on examination.  He was started on an immune modulator (Humira) to control his disease and referred for electrodiagnostic testing.  This was performed on 10 August 2006 and showed no radiculopathy or neuropathy.  He was also evaluated in pain management and a synthetic narcotic prescribed.  Lumbar motion was painful on examination.  He was followed up in neurology on 29 August 2006 and noted to have a normal motor examination.  In late August, he was changed from Humira to Enbrel.  He was seen in rheumatology on 26 September 2006 and reported some improvement in symptoms, but still had restricted motion of his back.  

At the VA Compensation and Pension examination performed on 2 October 2006, 3 months prior to separation, the CI reported that he had four exacerbations of his LBP for a total of 6 days over the past year.  Review of the records did not show that he had been placed on quarters during the prior year.  On examination, his posture was slightly stiff, but otherwise normal.  His gait was normal.  Spasm was documented.  The range-of-motion (ROM) was reduced and is charted below.  The neurological examination was recorded as indicating a sensory deficit of the thigh (side not specified) and left sided weakness (presumably, the leg).  However, under the neurological examination, the CI was noted to have normal sensory function, motor function and reflexes.  The Board cannot explain the discrepancy, but noted that the latter examination is consistent with the remainder of the record.  Mild joint narrowing was present on X-ray examination.  The narrative summary was dated 3 October 2006.  The CI reported improvement on the Enbrel.  He was noted to be in no acute distress and to have decreased ROM with flexion of the back, but this was not quantified.  X-rays were noted to have been normal, but a bulging disc had been seen on Magnetic Resonance Imaging (at a referral clinic; not in evidence).  Laboratory testing for AS was positive.  Tenderness of the paraspinal muscles was present.  The CI was referred to PT on 3 November 2006 for ROM testing; this is charted below, but it is not clear from the reports if this was for lumbar or thoracolumbar as PT notes from 9 and 3 November refer to each, respectively.  Regardless, the measurements were with a bubble inclinometer vice a goniometer.  The final note in the record prior to separation was in rheumatology and dated 5 December 2006, a month prior to separation.  The CI reported almost complete resolution of his symptoms and stated that he felt good enough to play tennis were it not winter.  His forward flexion had improved to 8 cm and his gait was brisk and normal.  

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	PT ~2 Mo. Pre-Sep	VA C&P ~3 Mo. Pre-Sep	
Flexion (90 Normal)	25/30/30	40	
Combined (240)	---	170	
Comment	lumbar spine versus thoracolumbar with a bubble inclinometer	Thoracolumbar	
§4.71a Rating	- 	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the AS condition at 10% using the code 5240 (ankylosing spondylitis).  The VA rated the back condition at 40% using the dual code 5240 and 5002 (rheumatoid arthritis).  It used the CI report of three episodes of incapacitation to support the 40% rating under the code 5002.  The Board noted that the CI does not have rheumatoid arthritis and determined that the use of this code is not appropriate.  The 5240 code is specific for AS, the unfitting condition.  The Board then considered the rating.  The ROM measurements obtained for the MEB were accomplished with an inclinometer rather than a goniometer.  In addition, it is not clear if these were for the lumbar spine or the thoracolumbar spine.  Accordingly, the VA measurements were assigned a higher probative value.  These measurements are also more consistent with the final clinical note prior to separation which recorded near resolution of symptoms.  The evidence does not support a determination that an unfitting radiculopathy was present at separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the ankylosing spondylitis 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 ankylosing spondylitis condition, the Board unanimously recommends a disability rating of 20%, coded 5240 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Ankylosing Spondylitis	5240	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131214, 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

XXXXXXXXXXXXXXXXX

Dear XXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-02720.

	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.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

XXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR