Search Decisions

Decision Text

AF | PDBR | CY2013 | PD-2013-02160
Original file (PD-2013-02160.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX     CASE: PD-2013-02160
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20141107
SEPARATION DATE: 20050214


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (3E151/HVAC Apprentice) medically separated for a back condition. The back condition 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 L4 profile placed on light duty and referred for a Medical Evaluation Board (MEB). The back condition, characterized as “chronic LBP” was forwarded to the Physical Evaluation Board (PEB) AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated “lower back pain” as unfitting, rated 10%, referencing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and DOD guidelines. The CI made no appeals and was medically separated.


CI CONTENTION: “Service connection lumbar strain has been so severe that has caused 2 spinal fusions and limited mobility with use of walking device.” [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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting back condition is addressed below and no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veteran Affairs, operating under a different set of laws. The Board considers VA evidence proximate to separation in arriving at its recommendations and DoDI 6040.44 defines a 12 months interval for special consideration to post-separation evidence. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.


 RATING COMPARISON :

Service IPEB – Dated 20041018
 VA - (2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Lower Back Pain 5237 10% Lumbar Strain 5237 10% 20050413
Other x 0 (Not in Scope)
 Other x 5 20050413
Rating: 10%
 Combined: 30%
* Derived from VA Rating Decision (VA RD ) dated 20050915 ( most proximate to date of separation)

ANALYSIS SUMMARY:

Lower Back Pain. The first record in evidence for the low back pain (LBP) was dated 2 July 2002, when the CI presented to the emergency room with an acute onset of LBP after playing basketball. A magnetic resonance image obtained on 4 September 2003 revealed that he had a bulging disc at L5-S1 which did not impinge upon the spinal cord or nerve roots. The CI’s back condition was managed conservatively with both duty limitation and physical therapy sessions; he did return to duty albeit he had recurrent episodes of back pain. The CI’s neurology evaluation obtained on 17 February 2004 was normal and without radiculopathy. X-rays images taken of the lumbar spine on 26 May 2004 were normal. During an orthopedist appointment dated 18 June 2004, the examiner indicated that the CI was not a surgical candidate for his back condition. The examination was unremarkable other than tenderness [to palpation] and his range-of-motion (ROM) was normal. At a follow up physical medicine appointment dated 24 September 2004, it was noted that a trial of [steroids] injections was not beneficial, CI’s ambulated (walked) with a normal gait and neurological examination as well as ROM was within normal limits. The CI was referred for MEB for persistent LBP.

The narrative summary (NARSUM) dated 30 September 2004 (approximately 5 months prior to separation); the CI reported a 2.5 years history of LBP “since moving a 300 pound smokestack”. No physician prescribe incapacitation (bed rest) was documented in service treatment records (STRs). On examination, the CI’s ROM was omitted from STRs, but motion was documented as not painful. The ambulation, neurological examination and provocative testing for nerve root irritation were all within normal range. The back muscles were tender but without spasms and the examiner specifically noted that there was no radiculopathy present.

The VA Compensation and Pension (C&P) examination was performed on 13 April 2005 (2 months post separation), but was not in evidence for the Board’s review. However, the VA rater did annotate their findings in the VARD dated 15 September 2005, in sufficient details which allowed usage by the Board for adjudication. The CI reported continuous pain despite treatment. There was mild accentuation of the normal lumbar lordosis and mild spasm from L4-S1. Flexion was limited to 75 degrees with pain, but the ROM was otherwise normal. No comments were made referencing the CI’s gait, but it had consistently been recorded as normal in STRs.

The Board directed its attention to its rating recommendation based on the above evidence. The PEB and VA both rated the back condition at 10% under coded 5237 (lumbosacral strain). The 10% rating is supported both by the loss of flexion and painful motion as recorded in the VA C&P examination. While spasm was present, it did not result in an abnormal gait or reversed lordosis. Physician prescribed incapacitation was not recorded. The Board found no route to a rating higher than that adjudicated by both the PEB and VA. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the back 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 lower 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 there be no recharacterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131022, 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-2013-02160

         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

Similar Decisions

  • AF | PDBR | CY2013 | PD-2013-01892

    Original file (PD-2013-01892.rtf) Auto-classification: Denied

    Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.The Board acknowledges the CI’s information regarding the worsening impairment with which her service-connected condition burdens her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity...

  • AF | PDBR | CY2013 | PD-2013-01588

    Original file (PD-2013-01588.rtf) Auto-classification: Denied

    The CI also attached a one-page statement to his application which was reviewed by the Board and considered in its recommendations. 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 chronic back pain s/p discectomy and fusion condition, the Board unanimously recommends...

  • AF | PDBR | CY2013 | PD-2013-01886

    Original file (PD-2013-01886.rtf) Auto-classification: Denied

    The chronic LBP, characterized as “chronic uncomplicated low back pain (slight/intermittent),” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.The Informal PEB adjudicated “chronic subjective low back pain, without neurologic abnormality”as unfitting, rated 10% with likely application of theVA Schedule for Rating Disabilities (VASRD).The CI made no appeals and was medically separated. The examination noted limited painful extension and normal flexion,...

  • AF | PDBR | CY2014 | PD 2014 00415

    Original file (PD 2014 00415.rtf) Auto-classification: Denied

    Low Back Pain Condition . The Board noted that the CI does not state when the nerve block was accomplished nor specify which evaluation followed it in his contention. I have carefully reviewed the evidence of record and the recommendation of the Board.

  • AF | PDBR | CY2012 | PD2012-00783

    Original file (PD2012-00783.pdf) Auto-classification: Denied

    RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW BRANCH OF SERVICE: ARMY SEPARATION DATE: 20030126 NAME: XXXXXXXXXXXXXX CASE NUMBER: PD1200783 BOARD DATE: 20130130 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SFC/E-4 (13B10/Artillery), medically separated for mechanical low back pain (LBP) secondary to back strain. The commander’s statement noted that the CI’s condition left him “incapable of...

  • AF | PDBR | CY2013 | PD-2013-01606

    Original file (PD-2013-01606.rtf) Auto-classification: Denied

    The Board directed attention to its rating recommendationbased on the above evidence.PEB rated the chronic LBP20%, coded 5237 (lumbosacral strain),citing flexion limited to 45 degrees and noting absence of radiculopathy.The VA rated the degenerative disease lumbar spine,back condition, at 10% ascoded 5243(intervertebral disc syndrome),citing the limitation of motion from the August 2004 C&P examination.The ROM reported at the time of the MEB NARSUM did not support a rating higher than the...

  • AF | PDBR | CY2013 | PD-2013-01492

    Original file (PD-2013-01492.rtf) Auto-classification: Denied

    The Board considered the 10% rating criteria – “localized tenderness not resulting in abnormal gait or abnormal spinal contour.” All exams proximate to separation documented paraspinal tenderness at the mid to lower lumbar regions and the only exam with ROM measurements documented normal thoracolumbar ROM.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...

  • AF | PDBR | CY2012 | PD2012-00084

    Original file (PD2012-00084.docx) Auto-classification: Denied

    No other conditions were forwarded for Physical Evaluation Board (PEB) adjudication. The examiner performed an additional ROM examination with three repetitions recorded as lumbar flexion 50, 50, and 50 degrees. The VA spine Compensation and Pension (C&P) examination performed on 25 March 2005 did not record thoracolumbar ROM but documented absence of tenderness and muscle spasm, with normal gait and posture.

  • AF | PDBR | CY2014 | PD-2014-01855

    Original file (PD-2014-01855.rtf) Auto-classification: Approved

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVeterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The PEB rated the chronic neck pain 0%, coded 5237 (cervical strain) and the VA rated it 20%.The Board considered that the CI was noted to have painful, mildly limited cervical ROM without noted muscle spasm at the MEB...

  • AF | PDBR | CY2013 | PD-2013-02503

    Original file (PD-2013-02503.rtf) Auto-classification: Denied

    The back condition, characterized as “ chronic low back pain” and “degenerative disk disease,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123 with no other conditions submitted by the MEB.The Informal PEB (IPEB) adjudicated “chronic low back pain associated with degenerative disc disease [DDD]” as unfitting, rated 10%,citing criteria ofthe VA Schedule for Rating Disabilities (VASRD).The CI appealed the fitness determination to the Formal PEB (FPEB), which affirmed the...