RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00793
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20070316

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Construction Mechanic, medically separated for “degenerative disc disease at L3-L4 and L4-L5,” with a disability rating of 10%.

CI CONTENTION:  Please consider all conditions at the time of separation.  The applicant’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20070209	VARD - 20070719	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Disc Disease at L3-4 and L4-5	5237	10%	Lumbar Spine Degenerative Disc Disease	5242	10%	20070208	
Mild Facet Arthropathy at L3-4, L4-5 and L5-S1	Cat II	Radiculopathy of the Right Lower Extremity	8521	10%	20070208	
Small Disk Protrusion with Annular Tear at L4-5	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Degenerative Disc Disease at L3-L4 and L4-L5 Condition (With Arthropathy and Disk Protrusion).  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lower back condition began in about 2001 after heavy lifting.  Magnetic resonance imaging studies April 2006 showed a very small central disc protrusion at L4-5 without central canal stenosis, mild facet degenerative change at L4-5 and L5-S1 and right L3-4 facet degenerative change mildly effaced the lateral aspect of the thecal sac.  The CI received three epidural steroid injections (ESI).  He was offered a lumbar fusion; however, he declined a surgical option.  At the time of the orthopedic clinic appointment on 30 August 2006, performed 7 months before separation, the CI reported “absolutely” no lower extremity (LE) pain or numbness but he continued to experience back pain which interfered with his daily activities.  On examination he appeared comfortable, his gait was normal and there were no focal motor or sensory deficits present in the LE.  At the time of the orthopedic clinic appointment on 13 September 2006, performed 6 months before separation, the CI reported 8/10 low back pain (LBP).  He indicated the ESIs had resolved his leg pain but not his LBP and he had numbness in the right LE and sharp pain in the left.  The evaluation by orthopedics concluded with a diagnosis of lumbar intervertebral disc syndrome.  During the orthopedic clinic appointment on 25 October 2006, performed 5 months before separation, the CI reported 5/10 LBP on average but he indicate it could become 7-8/10.  He had experienced tingling in the bilateral buttocks, but denied any numbness or weakness in the LE.  On examination he appeared slightly uncomfortable with a guarded gait; “heel and toe walking are demonstrated without motor deficits.”  Straight leg raise testing for radiculopathy was negative bilaterally; however at 80 degrees there was referred LBP.  There were no motor or sensory deficits in the LE.  Forward flexion demonstrated guarding with fingertips reaching the level of the patella with pain.  The evaluation by orthopedics concluded with a diagnosis of degenerative disc disease of L4-5 and L5-S1.  

Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “degeneration of lumbar or lumbosacral intervertebral disc,” “displacement of lumbar intervertebral disc without myelopathy,” and “osteoarthritis, unspecified whether generalized or localized, other specified sites” for PEB adjudication.  The MEB NARSUM examination on 26 October 2006, performed 5 months prior to separation, noted complaints of constant 3/5 LBP which radiated into his buttocks and both legs.  The pain increased with running, twisting and bending.  He indicated that after receiving ESIs his leg pain resolved; however, he still had occasional numbness and tingling into his right LE as well as sharp pain in his left leg.  He did not indicate bowel or bladder problems.  The physical examination showed a normal gait without limp or weakness.  Distal neurovascular systems were grossly intact, deep tendon reflexes were 1+ and equal bilaterally.  Disc and vertebral heights were well maintained and there was no evidence of spondylosis or spondylolisthesis.  The examiner noted the CI appeared uncomfortable.  There was tenderness to the lumbar paraspinal area without muscle spasm.  Straight leg raise testing for radiculopathy was positive on the left.  The range of motion (ROM) forward flexion of the lumbar spine indicated the fingertips were able to reach the mid-tibial region and all other planes showed a full ROM with pain.  The CI’s rebuttal to the MEB noted some differences in the onset of his back condition and focused on continuing back pain and radiating pain down both legs with functional loss.

At the VA Compensation and Pension (C&P) examination on 8 February, performed 1 month before separation, the CI reported 6/10 LBP which increased to 8/10 with standing, walking and running and pain into his hips and right leg with intermittent numbness in his foot.  There was no bladder or bowel incontinence.  The physical examination stated “as far as his gait, on ambulation he notes pain in his back.”  The CI was able to toe walk and heel walk but noted back pain.  Reflexes, strength and sensory exams were normal.  Forward flexion was 80 degrees (90 degrees normal) with back and right leg pain; the combined ROM was 180 degrees (240 degrees normal) with right and left lumbar pain.  The ROM was not additionally limited by pain, weakness, fatigue or lack of endurance on repetitive testing or flare-ups.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the degenerative disc disease condition at 10% coded 5237 (lumbosacral strain).  The PEB listed the mild facet arthropathy at L3-L4 and L4-L5 as well as the small disc protrusion with annular tear at L4-L5 conditions as a related diagnoses (Category II) contributing to the disability in this case.  The Board noted that these conditions were related diagnoses to the degenerative disc disease condition, would all be rated under the spine formula, and were not separate conditions which could be separately rated (§4.14 - avoidance of pyramiding).

The VA rated the lumbar spine degenerative disc disease condition at 10% coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 1 month before separation, citing limitation of motion with pain resulting in radiculopathy.  The VA also rated radiculopathy of the right lower extremity 10% coded 8521 (external popliteal nerve [common peroneal]) as mild incomplete paralysis based on the same VA C&P examination and citing pain and numbness that radiated down the leg.  The radiculopathy was related to the lumbar spine condition.

The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM and VA examinations.  Although not reported as goniometric measurements, the NARAUM physical examination demonstrated the CI flexed reaching fingers past the knees which exceeds 60 degrees of thoracolumbar flexion.  Alternatively, painful motion or tenderness would support the 10% rating level.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.

The Board considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome.  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had a disc protrusion with radicular pain and intermittent numbness.  There were symptoms of radiating pain documented in the treatment records and sciatica was noted on the LIMDU; however, examinations indicated normal strength, reflexes and gait, and the sensory changes did not affect his job.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  The Board therefore concluded that additional disability rating was not justified 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 degenerative disc disease at L3-L4 and L4-L5 condition.

BOARD FINDINGS:  In the matter of the degenerative disc disease at L3-L4 and L4-L5 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.  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 20140210, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 12 Apr 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC 
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC