RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-00715
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140911
Separation Date:  20040512

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (4T051/Medical Lab Journeyman) medically separated for a back condition.  This condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  She was issued a temporary P4 profile and referred for a Medical Evaluation Board (MEB).  Low back pain (LBP) with radiculopathy, characterized as not meeting retention standards, was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded six other conditions.  The Informal PEB (IPEB) adjudicated low back pain with radiculopathy as Category I (unfitting), rated at 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) and DoDI 1332.38.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Review by PDBR”

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 those conditions identified, but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting low back condition is addressed below.  The Category II (pancreatitis; adrenal hyperplasia; plantar fasciitis; ovary and headaches) and Category III (obesity) conditions were determined as not-unfitting and not contended, thus are not within the DoDI 6040.44 defined purview of the Board.  Those, and any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20040219 | VA* - (2 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Low Back Pain with Radiculopathy | 5237 | 10% | Mild Central Bulge L3-4 | 5243 | 10% | 20040315
Other x 6 (Not in Scope) | Other x 7 (Not in Scope) | 20040315
Combined:  10% | Combined:  40%
*Derived from VA Rating Decision (VARD) dated 20040518 (most proximate to date of separation)

ANALYSIS SUMMARY:

LBP with Radiculopathy Condition.  The CI developed LBP in June 2003 without a specific injury identified.  She was seen in family practice for LBP that radiated to hip and down her legs.  The physical exam findings were an antalgic gait, tender to palpation (TTP), abnormal straight leg raise and abnormal range-of-motion (ROM); however, reflexes, motor and sensory exams were normal.  The examiner ordered quarters for 24 hours, for rest.  The physical therapist (PT) documented chronic LBP with tingling that radiated into the right lower extremity into the toes.  The CI reported functional limitation of bending over, and quick or prolonged movements.  The physical exam findings were full ROM standing, decreased LBP with extension, tenderness in the medial aspect of the left piriformis muscle, 4+/5 strength in both lower extremities and normal reflexes.  The examiner diagnosed left-sided sacroiliac joint dysfunction.  A lumbosacral spine X-ray was normal.  A lumbar spine magnetic resonance imaging (MRI) showed a mild central disc bulge at L3-4 with mild central canal narrowing and minimal arthritic changes at L4-  The examiner noted that the CI had some relief for the LBP with oral steroids and was given a steroid injection on 9 October 2003.  The family practitioner noted LBP, which radiated to both legs.  She requested additional PT treatment due to her worsening symptoms.  The physical findings were TTP of the lumbosacral spine and ROM with normal reflexes, sensation and strength.  The CI continued with PT and family practice without any improvement in the LBP symptoms.  A repeat lumbosacral spine X-ray was normal.  The CI was given a P4 profile for chronic pancreatitis, congenital adrenal hyperplasia, migraines and LBP radiculopathy.  The commander’s statement noted that although the CI maintained an excellent attitude and worked full duty shifts when she was physically and medically able, she missed 3 weeks of work due to illness and her conditions precluded her from full-time duty.

The MEB narrative summary (NARSUM) exam (approximately 3 months prior to separation) documented that the CI had constant, burning, sharp middle-to-lower back pain rated at 7/10.  Pain was worse with physical activity, relieved by rest and pain medications.  She had undergone injections for the LBP which allowed some improvement with pain and increased her ability to performed activities.  There were no ROM’s done at this exam.  Three months prior to separation, a family practice provider noted LBP that radiated into the lower extremities, a burning sensation with left knee and outer thigh numbness.  The physical exam findings are summarized in the chart below.

The VA Compensation and Pension (C&P) exam (approximately 2 months prior to separation) documented constant, burning, sharp, chronic middle and LBP which radiated down both legs, made worse by activity and relieved by rest, narcotics and medication for neuralgia.  She rated the pain 7/10 and at times required complete bed rest of 3-5 days.  The functional limitations were an inability to lift any significant weight.  She had constant pain that radiated down her legs with the back pain, reported left-sided knee numbness with shooting, tingling and burning pain down both sides.  Due to the LBP with radiculopathy, she was unable to take out the trash, push a lawnmower, garden or do any significant shopping; however she was able to work as a laboratory technician.  The VA C&P physical exam findings are summarized in the chart below.

The ROM evaluations in evidence, which the Board weighed in arriving at its rating recommendations, are summarized in the following chart:

Thoracolumbar ROM (Degrees) | Fam. Practice 3 Mos. Pre-Sep | VA C&P 2 Mos. Pre-Sep
Flexion (90 Normal) | Decrease ROM | 90
Combined (240) | -- | 240
Comment | Normal gait; Pos. tenderness to palpation; No spasm; Normal strength, sensation & reflexes | Normal gait; No painful motion or spasm; Pos. tenderness; Neg. straight leg raise; Normal strength, sensation & reflexes
§4.71a Rating | 10% | 10%
The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the LBP with radiculopathy condition as 5237 (lumbosacral or cervical strain), rated at 10%.  The PEB document contained the following passage, “while none of member's conditions is singularly unfitting, the IPEB opines member's total condition renders her unfit and rates the most persistent/highest rated condition.”  The VA coded the mild central bulge L3-4 with mild canal narrowing and minimal facet change L4-5 with sciatica condition as 5243 (intervertebral disc syndrome), rated at 10%.  The General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease.”  Both exams proximate to separation were consistent with a 10% rating IAW the General Rating Formula.  The VA coded and applied its 10% rating based on incapacitating episodes; however, there was no documentation of bed rest prescribed by a physician as required to apply the incapacitating episode rating criteria.  Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  The sensory component in this case has no functional implications and there was no motor impairment that could be linked to significant physical impairment.  There is thus no evidence of a separately ratable functional impairment (with fitness implications) from the residual radiculopathy and the Board cannot support a recommendation for an additional disability rating on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the LBP with radiculopathy 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.  As discussed above, PEB reliance on DoDI 1332.38 for rating LBP with radiculopathy was operant in this case and the condition was adjudicated independently of that instruction by the Board.  In the matter of the LBP with radiculopathy 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 20140206, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-00715

	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,

							
XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

PD-2014-00715