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AF | PDBR | CY2014 | PD-2014-00914
Original file (PD-2014-00914.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX        CASE: PD - 2014 -00914
BRANCH OF SERVICE: AIR FORCE      BOARD DATE: 201 5 0422
Separation Date: 20090829


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Aircraft Hydraulic System Craftsman) medically separated for back pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards. He was placed on limited duty and referred for a Medical Evaluation Board (MEB). The condition, characterized as “chronic lower back pain ( LBP) , ” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB adjudicated the LBP s tatus p ost ( s / p ) s pinal f usion condition as unfitting and rated it at 20%. The CI made no appeals and was medically separated.


CI CONTENTION : “Knee, shoulder, and back injuries make it extremely difficult to perform the functions of any physically demanding job . ”


 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 Veterans Affairs Schedule for Rating Disabilities (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 20090526
 VA - (22 Months Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
LBP s/p Spinal Fusion 5241 20% Post Laminectomy Syndrome and Degenerative Disc Disease (DDD) 5241 20% 20110609
Other x 0
 Other x 1
Combined: 20%
 Combined: 20%
Derived from VA Rating Decision (VARD) dated 20111018 (most proximate to date of separation [DOS])


invalid font number 31502


ANALYSIS SUMMARY :

LBP s/p Spinal Fusion Condition . The CI had a long history of significant LBP. He underwent a laminectomy in March 2007 for left leg pain. The civilian Neurosurgeon noted worsening of the LBP along with back spasms with minimal activity. There were physical exam findings of vertebral spine tenderness; paraspinal tenderness ; and limited range - of - motion (ROM) by pain in in flexion and extension. The CI underwent a n L4-5 spinal fusion in April 2008. The civilian Neurosurgeon noted that the CI continued to have episodic back pain , which was caused from activities such as overhead lifting and heavy repetitive li fting. A pproximately 9 months prior to separation a physical therapist performed ROMs for the MEB exam , which are summarized below. The MEB narrative summary (NARSUM) exam approximately 7 months prior to separation documented that the CI had significant problems with bending at the waist and with heavy lifting. At the time of the MEB, the CI was in an administrative position; however, he anticipated being deployed in the future where he would be expected to perform manual labor. The examiner opined that the CI would be unable to perform heavy manual labor such as heavy lifting and bending. The MEB NARSUM physical exam findings are summarized in the chart below. A primary care provider documented stiffness in the lower back with aggravation of pain on bending and if sitting or standing for greater than 10 minutes. An a ddendum t o the MEB documented no significant change in the CI’s medical status and that he had been seen for an exacerbation of back spasms by his civilian medical provider. The VA Compensation and Pension (C&P) exam approximately 22 months after separation documented that the CI’s back pain was progressively worse and he always had pain. The VA C&P physical exam findings are summarized in the chart below.
There were three ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.
Thoracolumbar ROM (Degrees)
 PT & NARSUM ~9 & 7 Mos. Pre-Sep PCC ~ 6 Mo. Pre-Sep VA C&P ~ 22 Mo. Post-Sep
Flexion (90 Normal)
 60 60 60
Combined (240)
 - 125 130
Comment
 For MEB; Pos. tenderness to palpation; st raight leg raise negative; Normal strength & reflexes No spasm appreciated Pos. painful motion & tenderness to palpation; Normal strength sensation & reflexes
§4.71a Rating
 20% 20% 20%
invalid font number 31502
The Board direct ed attenti on to its rating recommendation based on the above evidence . The PEB coded the LBP s/p spinal fusion condition as 5241 ( Spinal fusion ) and rated at 20%. The VA coded the post laminectomy syndrome and DDD condition as 5241 and rated at 20%. 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 . ” There was consistent documentation that the ROM flexion was 60 degrees on all three exams present for review; therefore, the CI met the 20% rating criteria of “Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees . ” 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 s / p spinal fusion 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 LBP s/p L4-5 spinal fusion 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 20 140220 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record






XXXXXXXXXXXXXXXXXXXX
President
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 (Section 1554, 10 USC), PDBR Case Number PD-2014-00914.

         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

cc:
SAF/MRBR

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