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AF | PDBR | CY2013 | PD-2013-01213
Original file (PD-2013-01213.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-01213
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20150115
SEPARATION DATE: 20040324


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Security Forces Journeyman) medically separated for myofascial (muscle and its surrounding fascia connective tissue wrapping) back pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards. He was issued a temporary P4/L2 profile and referred for a Medical Evaluation Board (MEB). The myofascial back pain condition, characterized as “chronic myofascial back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated “myofascial back pain” as unfitting, rated 10%, citing criteria of the Department of Defense Instruction (DoDI) 1332.39 and VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “The issue why the rating should be changed is because it does not reflect nor is it equivalent to the condition that ended my military career abruptrly.” [sic]


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 20040123
 VA - (9 Years 4 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Myofascial Back Pain 5021-5099 10% Chronic Lumbar Strain (claimed as spinal condition) 5237 10% 20130520
Other x 0 (Not in Scope)
 Other x 0 (Not in Scope)
Combined: 10%
 Combined: 10%
Derived from VA Rating Decision (VA RD ) dated 20130628 ( most proximate to date of separation [ DOS ] ).



ANALYSIS SUMMARY:

Myofascial Back Pain Condition. The CI noted low back pain in the right and left flank areas for approximately 2 months based on an outpatient screening form in the treatment record dated 24 February 2003. A vaccine adverse event report was completed on 11 March 2003 that indicated the CI received a second dose of anthrax vaccine on 16 December 2002 and reported 10 days later on 26 December 2002 symptoms of hematuria (blood in urine), back and side pain, fatigue and a history of sickle cell trait. Treatment for presumptive prostatitis did not resolve the CI’s back pain. Because repetitive bending and prolonged standing aggravated his condition, he was referred to Physical Medicine and Rehabilitation (PM&R) and was seen on 2 April 2003 at which time the CI reported no history of trauma, although he carried a 50-pound rucksack daily. The pain, which was described as dull and ranged from 3/10 (10 being the worst pain) to 8/10 with prolonged standing, was without numbness, tingling, weakness, or radiation. He had an antalgic gait to the right, with a straight spine, decreased lumbar lordosis, mild lumbar muscle spasm, and tender areas of the mid lumbar area, and tight, slightly tender gluteal muscles of the buttocks. On 29 April 2003, a full range-of-motion (ROM) was noted with pain at the extremes with tenderness of the lumbosacral spine areas without spasm. Nonsteroidal anti-inflammatory medication was prescribed. Lumbar spine X-rays were unremarkable. A PM&R consultation on 28 May 2003 noted the CI’s report of painful flare-ups without bowel or bladder incontinence (leakage); and, gait and curvature of the spine were normal. Multiple physical therapy modalities and treatments were instituted. Renal (kidney) and electro-diagnostic studies were negative. Examination revealed the CI had an unremarkable gait, but had significantly poor posture with head forward carriage and rounded-shoulders. The lumbar ROMs were normal; and, there was no lumbar paravertebral (around the spine) tenderness and significant tightness along the lumbar paravertebral muscles. Neurologic examination was unremarkable. The pain was felt most likely to be myofascial in nature; and, treatment consisted of a muscle relaxant and pain medication with continued physical therapy, which ultimately did not help. Bone scan results showed normal uptake within the spine. A transdermal narcotic medication initially helped, but its effect was dose dependent. A revised temporary P4 profile from a prior L2 was issued on 1 October 2003 for myofascial back pain with restrictions of light/clerical duty only and no carrying a weapon while on pain medication. Follow-up examinations in November and December 2003 noted paraspinal tenderness of the lumbar muscles, a negative straight leg raise test (nerve root irritation), and functional ROMs of the lower back.

The commander’s statement dated 8 December 2003 indicated the CI had “a medical condition affecting his ability to perform normal military duties . . . is not working in his primary duty position . . . is unable to carry a weapon [and] was returned from a deployed location because of his condition and is not deployable.” The narrative summary dated 16 December 2003 addressed noted the CI’s history of lower back pain and the various treatments and added he was “experiencing limitations at work, home, and social activities secondary to his back pain.” He had a full ROM with tenderness of the midline/paraspinal area from L2-S1 and the examination was otherwise unremarkable. The final diagnosis was chronic myofascial back pain. No VA Compensation and Pension (C&P) exam was performed proximate to separation, however, the CI was evaluated in a VA primary care clinic on 20 July 2004, 4 months after separation, and reported ”no back pain at this time” and was taking no medications. No record of an examination of the spine for that visit was in evidence, but the extremities and neurological evaluations were unremarkable. The impression was that the “myofascial pain in the low back was in remission.” Temporally remote (more than 2 and 9 years respectively post-separation) VA C&P examinations were reviewed; however, they offered very limited or no probative post-separation evidence of any significant value.

The Board directed attention to its rating recommendation based on the above evidence. The IPEB applied a 10% rating using the VASRD analogous code 5021 (myositis) for myofascial back pain (annotated with an ICD-9 code of 724.2 for lumbago [lower back pain]). For rating purposes, code 5021 uses code 5003 when ROMs are not noncompensable under the appropriate diagnostic codes as long as there are objective signs of pain on motion or muscle spasm, which was present. Muscle spasm and an abnormal spinal contour and gait noted a year prior to separation noted a year prior to separation were never again observed. Therefore, the next higher 20% rating is not supported. The VA assigned a rating of 10% using code 5237 (lumbosacral), albeit more than nine years post separation and of very limited probative value. The Board does not change codes in the absence of a rating change; and, since it was unable to find a route for a higher rating, the PEB analogous code was not modified or changed. 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 myofascial back pain 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 1332.39 and the VASRD for rating the myofascial back pain was operant in this case and the condition was adjudicated independently of that instruction, but consistent with the VASRD, by the Board. In the matter of the myofascial back pain 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 20130909, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








                          
XXXXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review


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

 Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-01213.
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,
XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

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