RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-01656
BRANCH OF SERVICE:  NAVY		SEPARATION DATE:  20080718

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Aircrew Survival Equipment, medically separated for “lumbar radiculopathy, status post microdiscetomy,” with a disability rating of 10%.

CI CONTENTION:  The Navy should have rated me 90% like the VA.  The CI’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 - 20080407	VARD – 20080822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Radiculopathy, s/p Microdiscetomy	5243	10%	S/P Lumbar Discectomy	5237	20%	20080519	
Bilateral Lower Extremity Causalgia	Cat II	Left Leg Shin Splints	5299-5262	NSC	20080519	
		Right Leg Shin Splints	5299-5262	NSC	20080519	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Lumbar Radiculopathy status post Microdiscetomy (Category II Bilateral Lower Extremity Causalgia).  The first record in evidence for lower extremity symptoms is a family practice note dated 24 January 2006 which records a 2-month history of “shin splints.”  Conservative management including weight loss (he was on the weight control program), decreased activity, better supporting shoes, and ice application after exercise were recommended.  A bone scan on 7 March 2006 was consistent with shin splints without stress fractures.  Despite treatment, his pain persisted right greater than left.  He was evaluated in orthopedics on 2 August 2006 and the diagnosis was confirmed.  He was noted to have a normal neurological examination and well as X-rays.  He was given a duty excuse for physical training and an MRI consult.  The consult accomplished on 21 August 2006 did not confirm the findings from the bone scan.  In orthopedics a week later, continued conservative treatment including physical therapy for shin splints was recommended.  In physical therapy on 20 September 2006, his physical examination was again consistent with shin splints.  The gait and neurological examination were normal.  He was issued orthotics.  The CI noted that standing on a concrete floor working as a parachute rigger aggravated his leg pain.  He was seen by a different orthopedic surgeon on 8 November 2006 and reported persistent pain despite treatment and limited activity.  He also noted a weight gain due to decreased activity.  Consideration of limited duty was recommended.  In physical therapy on 4 December 2006, he reported persistent pain, but also occasional numbness in both legs from the knees to the ankles.  In orthopedics on 17 January 2007, he reported essentially no change in his pain.  The diagnosis remained shin splints.  A bone scan was repeated on 2 February 2007 and 7 March 2007.  The first did not show shin splints, however, the second was consistent with shin splints.  A persistent stress reaction was noted on review in orthopedics 2 days later; the diagnosis remained shin splints.  However, when seen by the same orthopedic surgeon on 23 April 2007, the diagnosis was changed to causalgia and shin splints even though the symptoms and examination were unchanged.  The rationale was not documented.  

The Board noted that causalgia is an older term for complex regional pain syndrome (CRPS), a condition in which there is chronic pain following an injury maybe out of proportion to the injury.  It is often associated with skin changes, sweating, and swelling.  These were not documented at this orthopedic encounter or subsequent clinical visits.  He was then seen in physical medicine and rehabilitation (PMR) and thought to have limb pain of an unknown etiology.  In the pain clinic that same day, he was also noted to have limb pain of an unknown etiology.  The symptoms were not completely consistent with CRPS.  An MRI of the tibia and fibula on 31 May 2007 was normal.  As part of the work up for his condition, Vitamin D levels were assessed and found to be low.  This was thought to be a possible cause of the pain (but not CRPS itself) and he was given supplemental Vitamin D.  Electrodiagnostic studies (EDX) were normal.  He was then evaluated in rheumatology on 20 June 2007.  The CI reported a 2-year history of limb and lower back pain which was thought to not be of an inflammatory basis or related to a connective tissue disease (such as lupus).  An MRI of the back the next day showed degenerative disc disease (DDD) at L5-S1.  This was noted to be non-concordant with the limb pain in the pain clinic on 26 June 2007.  The same day, the rheumatologist wrote that he did not believe that the CI had either a systemic autoimmune or an inflammatory process and that the specific cause of his pain was unclear.  In orthopedics on 16 July 2007, the CI was again noted to have causalgia and the Vitamin D deficiency was noted as a possible cause of his pain.

In primary care the next day, the CI was noted to have increasing low back pain (LBP), but no evidence for a radiculopathy was present.  The CI was evaluated in neurosurgery on 10 September 2007.  He reported progressive LBP which radiated in both lower extremities (BLE) and was the cause of the majority of his discomfort.  The MRI was reviewed and impingement of the left S1 nerve root was noted.  It was thought that his pain was from a muscular response (guarding) to the disc herniation.  Surgery was recommended and an L5-S1 discectomy accomplished on 4 October 2007.  In follow-up on 19 October 2007, he was noted to be improving with a decrease in his left lower extremity (LLE) pain.  On 28 December 2007, the CI reported leg greater than back pain.  He again reported painful shin splints aggravated by being overweight and doing a lot of running.  In a follow-up in neurosurgery in January 2008, it was determined that the CI would not be able to return to full duty.  He was then entered into the Medical Evaluation Board (MEB) process.

At the MEB examination on 4 February 2008, approximately 6 months before separation, the CI reported ongoing back and lower leg pain with numbness and tingling in BLE.  The examination showed tenderness over the shins bilaterally and also the lower back.  The neurological and skin examinations were normal.  The MEB narrative summary (NARSUM) was dated 17 March 2008.  It was recorded that the October 2007 surgery had not provided complete relief of his LBP and that the CI had completed two limited duty periods.  The range of motion (ROM) was noted to be limited by pain, but not quantified.  The neurological examination was normal.  The tibiae were tender bilaterally, but no swelling or deformity of the lower extremities was present (associated with CRPS).

At the VA Compensation and Pension (C&P) examination performed on 19 May 2008, 2 months before separation, the CI reported back pain manifested by stiffness, weakness, and numbness with radiation down his legs.  The pain from radiation was described as “crushing, squeezing, burning, aching, sharp, sticking, and cramping.”  The same description was applied for the shin splints.  He reported no limitations in daily activities other than not being able to push a lawn mower or to garden.  Incapacitation was reported after surgery, but not otherwise.  This was because bending (back) hurt.  His posture and gait were normal.  Examination of the tibia (shin bone) and fibula were normal.  Examination of the back revealed tenderness without spasm.  The ROM was limited in flexion to 40 degrees (90 normal) and the combined ROM was 120 degrees (240 normal).  There is no further limitation with repetition and signs of intervertebral disc disease were absent.  The scar was well healed.  X-rays of the lumbar spine and bilateral tibiae and fibulae were normal.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the back at 10%, coded 5243 (intervertebral disc syndrome).  Causalgia of BLE was noted to be a Category II condition (contributing to the unfitting condition, but [implied] not separately unfitting).  Vitamin D deficiency was noted to be a Category III condition.  The VA rated the back condition at 20%, coded 5237 (lumbosacral strain).  The scar was non-compensable.  Bilateral shin splints were not service connected as the examination was normal at the VA C&P evaluation.  No VA comment was made on the causalgia or Vitamin D deficiency conditions.  The Board noted that the ROM documented by the VA C&P examiner supported a 20% rating.  No route to a higher 20% rating for the back condition was found.

The Board then considered if the Category II causalgia condition was separately unfitting and ratable.  The Board noted that the primary symptom was lower leg pain which was also attributed to the back condition and described identically at the VA C&P examination, the most proximate to separation.  Examination of BLE at this examination was normal without skin findings or an abnormal neurological examination.  The leg pain is subsumed under the back condition and a separately unfitting condition is not present at separation.  The PEB rated the CI for lumbar radiculopathy; however, the neurological examination was normal at the MEB, NARSUM, and VA C&P examinations.  The Board also considered if the Vitamin D condition contributed to the unfitting back condition.  While Vitamin D deficiency can contribute to bone loss which can result in pain, this is not demonstrated on multiple radiological studies.  The back pain was thought to be from the disc disease and subsequent surgery.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the back condition.  Spinal fusion, code 5241, is thought to better describe the unfitting condition and is also recommended.  The Board did not find evidence to support a separately unfitting radiculopathy.

BOARD FINDINGS:  In the matter of the back condition, described by the PEB as lumbar radiculopathy s/p microdiskectomy, the Board unanimously recommends a disability rating of 20%, coded 5241 IAW VASRD §4.71a.  In the matter of the Category II BLE causalgia and Category III Vitamin D deficiency, the Board recommends no change in the PEB adjudication and that neither condition is separately unfitting.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Lumbar Radiculopathy, S/P Microdiskectomy 	5241	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140414, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 28 Mar 16 ICO XXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 30 Mar 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 28 Mar 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 28 Mar 16 ICO XXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 31 Mar 16 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USN: Assignment to the Temporary Disability Retired List for six months effective date of discharge with a 50 percent disability rating followed by transfer to the Permanent Disability Retired List with a final disability rating of 30 percent.

     b. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent disability rating effective date of discharge.

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
 
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.