RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:                                BRANCH OF SERVICE:  AIR FORCE
CASE NUMBER:  PD201000353                           SEPARATION DATE:
 20071226
BOARD DATE:  20111026
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SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered individual (CI) was an  Active  Duty  SSGT  (E-5)
Loadmaster (1A251), medically separated from the Air Force for chronic  back
pain in 2007.  He did not respond adequately to treatment and was unable  to
perform within his  Air  Force  Specialty  (AFS)  or  to  participate  in  a
physical  fitness  test.   He  was  issued  a  permanent  P4L4  profile  and
underwent a Medical Evaluation  Board  (MEB).   Degeneration  of  lumbar  or
lumbosacral intervertebral disc levels L3-S1 was forwarded to  the  Physical
Evaluation Board (PEB) as medically unacceptable IAW AFI 48-123.   No  other
conditions  appeared  on  the  MEB  submission.   Bilateral  carpal   tunnel
syndrome (Bil CTS),  anterior  compartment  syndrome,  and  gastroesophageal
reflux disease (GERD) were identified in the NARSUM and  will  be  discussed
below.  The Informal PEB (IPEB) adjudicated the chronic back pain disc  with
disc protrusion of L4-L5 and L5-S1 as  unfitting  and  rated  it  20%,  with
application  of   the   Veterans’   Administration   Schedule   for   Rating
Disabilities (VASRD).  The CI made no appeals and  was  medically  separated
with a 20% combined disability rating.
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CI CONTENTION:  “Member was found to be medically unfit  for  duty  by  PEB,
deemed disabled because  of  injuries  sustained  in  the  line-of-duty  and
subsequently, involuntarily, discharged from military service.  Furthermore,
the  disability  rating  percentage  awarded  the  member  by  the  PEB   is
significantly lower in comparison to the percentage at  which  the  Veterans
Administration Disability Rating System has  determined.”   He  additionally
lists all of his VA conditions and ratings as per the  rating  chart  below.
A contention for their inclusion  in  the  separation  rating  is  therefore
implied.  Item 16 also noted  that  he  was  diagnosed  with  post-traumatic
stress disorder (PTSD).
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RATING COMPARISON:
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|Service IPEB – Dated 20071029  |VA (3 Mo. Post  Separation) – All Effective |
|                               |Date 20071227                               |
|Condition                      |Code                            |Rating     |
|Final Combined:  20%           |Total Combined:  50%                        |

ANALYSIS SUMMARY:  The Board acknowledges the  sentiment  expressed  in  the
CI’s application, i.e., that there should be additional disability  assigned
for  his  other  conditions  and  for  the  gravity  of  his  condition  and
predictable consequences which merit consideration for a  higher  separation
rating.  While the Medical Disability Evaluation  System  considers  all  of
the service member's medical conditions, compensation can  only  be  offered
for those medical conditions that cut short a service member's  career,  and
then  only  to  the  degree  of  severity  present  at  the  time  of  final
disposition.  However, the Department of Veterans Affairs,  operating  under
a different set of laws (Title 38, United  States  Code),  is  empowered  to
periodically  re-evaluate  Veterans  for  the  purpose  of   adjusting   the
disability rating should his degree of impairment vary  over  time,  and  to
compensate for all service connected conditions without tie to fitness.

Chronic back pain with disc protrusion of L4-5  and  L5-S1:   The  CI  first
injured his back in 1999 while lifting boxes.  He responded to  conservative
treatment and was able to pass an  initial  Flying  Class  III  medical  for
training as a C-17  Loadmaster.   He  functioned  well  in  this  AFS  until
December  2005  when  he  re-injured  his  back  while  bowling.   His  pain
persisted despite conservative management. An MRI performed  on  10  January
2006 revealed degenerative disc disease (DDD) at L3-L4 and  right  eccentric
disc bulging, L4-L5 with central protrusion and foraminal narrowing, and L5-
S1 loss of disc height with foraminal arthritis, L>R.  Over  the  course  of
the next two years, his exams showed normal sensation,  motor  function  and
deep tendon reflexes (DTRs) while range of motion  (ROM)  was  noted  to  be
reduced.  Oral medications and epidural steroid injections (ESI)  failed  to
resolve his symptoms, while facet injections did provide  temporary  relief.
The  MEB  exam  was  sequential  over  three  visits,  but  the   last   was
accomplished 28 September 2007, three months  prior  to  separation.   There
was flexion limited to the waist, similar  to  previous  exams.   There  was
point tenderness over L4-5.  Gait was normal as were the DTRs.  Muscle  tone
was also normal.  The CI noted pain which radiated down the  right  leg  and
an intermittent vibrating sensation  in  the  right  heel,  especially  when
riding a stationary bicycle.

The VA compensation and pension (C&P)  examination  was  performed  9  April
2008, three and a half months after separation.  The CI had  pain  radiating
down the thighs to the back of the knees bilaterally.  There  was  no  bowel
or bladder dysfunction.  On physical exam,  sensory  and  motor  exams  were
normal, as were DTRs and straight leg raise with the  exception  of  reduced
sharp sensation over the lateral leg  near  the  fibular  head.   Repetitive
motion was attempted, but the patient was unable to do this  and  complained
of pain when only flexing  forward  5  degrees  and  then  made  no  further
attempt at motion.  There were  three  goniometric  range  of  motion  (ROM)
examinations proximate to separation.

|Goniometric ROM|PT  20070327 |PT  20079629 |MEB 20070928 |VA C&P       |
|- Thoracolumbar|9 Mo. Pre-Sep|6 Mo. Pre-Sep|3 Mo. Pre-Sep|20080409     |
|               |             |             |             |3.5 Mo.      |
|               |             |             |             |Post-Sep     |
|Ext (0-30)     |(26) 25⁰     |(24) 25⁰     |             | 5⁰          |
|R Lat Flex     |(14) 15⁰     |(12) 10⁰     |             |10⁰          |
|(0-30)         |             |             |             |             |
|L Lat Flex     |(16) 15⁰     |(14) 15⁰     |             |10⁰          |
|0-30)          |             |             |             |             |
|R Rotation     |(38) 40⁰     |(36) 35⁰     |             |10⁰          |
|(0-30)         |             |             |             |             |
|L Rotation     |(34) 35⁰     |(32) 30⁰     |             |10⁰          |
|(0-30)         |             |             |             |             |
|COMBINED (240) |(204) 205⁰   |(192) 190⁰   |             |60⁰          |
|Comment        |Neg Waddells,|Neg Waddells,|ROM similar  |Three        |
|               |symm gait,   |symm gait,   |to prior     |Waddells     |
|               |neg guarding |neg guarding |exams        |positive; nml|
|               |             |             |             |gait         |
|§4.71a Rating  |10%          |10%          |             |40%          |

The ROM values reported by the VA examiner, three and a  half  months  after
separation, are significantly worse than those reported  by  the  MEB  dated
three months before separation  and  the  goniometric  exams  six  and  nine
months prior to separation.  There is  no  record  of  recurrent  injury  or
other development in explanation of the marked impairment reflected  by  the
VA measurements.  The  values  reported  were  derived  from  reported  pain
threshold with motion and the  examiner  stated,  “Waddell  signs:  positive
tenderness to light touch, positive pain with axial rotation, low back  pain
with light, cervical compression.”  The exam was performed  in  the  context
of expressly providing a basis for disability rating; thus subject  to  loss
of objectivity.  The Board, therefore, assigns a higher probative  value  to
the MEB examination as a basis for its  recommendations.   The  Board  notes
that the IPEB coded the back pain as  5243  (intervertebral  disc  syndrome)
rated 20%.  The VA also coded the back condition as 5243, but  rated  it  at
40% based upon a reduced ROM.  The Board determined that the ROM exam  rates
10% and discussed the IPEB rating of 20%.  The Board concluded that the  PEB
fitness adjudication for the back condition possibly included the  radiating
pain; however, it is not clear.  There was  no  evidence  that  this  was  a
separately unfitting condition and warranted a separate rating.   The  Board
considered whether the radiating  pain  (radiculopathy)  was  unfitting  and
noted that  neither  the  IPEB  nor  VA  separately  rated  it.   After  due
deliberation, in consideration of the totality of the  evidence,  the  Board
determined that there was insufficient cause to recommend a change from  the
PEB fitness adjudication for the back condition.

Other PEB Conditions:  None

Other Contended Conditions:  The CI’s application asserts  that  compensable
ratings should be considered for left shoulder impingement  syndrome,  right
CTS, bilateral  shin  splints  and  GERD.   All  of  these  conditions  were
reviewed by the action officer and considered by the Board.   There  was  no
evidence for concluding that any of  the  conditions  interfered  with  duty
performance to a degree that could be argued as  unfitting.   There  was  no
evidence that PTSD nor any other  mental  condition  was  present  while  on
active duty.  The Board determined,  therefore,  that  none  of  the  stated
conditions were subject to Service disability rating.

Remaining Conditions:   No  other  conditions  were  noted  in  the  NARSUM,
identified on the MEB physical, or found elsewhere in  the  DES  file.   The
Board does not have the authority under DoDI 6040.44 to  render  fitness  or
rating recommendations for any conditions not considered  by  the  DES.   No
other conditions were service connected with a compensable rating by the  VA
within twelve months of separation or  contended  by  the  CI.   The  Board,
therefore,  has  no  reasonable  basis  for  recommending   any   additional
unfitting conditions for separation rating.
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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.  In the matter  of  the  back  condition,  the
Board  recommends  no  re-characterization.   In  the  matter  of  the  left
shoulder, right CTS, bilateral shin  splints,  GERD,  radiculopathy  or  any
other condition eligible for  Board  consideration,  the  Board  unanimously
recommends these cannot be added as additionally  unfitting  conditions  for
rating at  separation  and  agrees  that  there  were  no  other  conditions
eligible for Board consideration which could be recommended as  additionally
unfitting for rating at separation.
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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  |
|Chronic back pain, with disc protrusion of L4-5   |5243        |20%     |
|and L5-Sl                                         |            |        |
|COMBINED    |20%     |


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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20100314, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.




                                        President
                                                                    Physical
Disability Board of Review
SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews MD  20762



      Reference your application submitted under the provisions of DoDI
6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2010-00353.

      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
with severance pay.

      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,







                                       Director
                                       Air Force Review Boards
                                       Agency

Attachment:
Record of Proceedings