RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03659
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20031228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Utilitiesman, medically separated for a back condition with a disability rating of 10%.  

CI CONTENTION:  The CI’s conditions continue to worsen and negatively impact his daily activities and that he was not evaluated on his mental health conditions.  His 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 based upon a 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 - 20030821	VARD - 20041108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mild Disk Protrusion at L5-S1	5295	10%	Lumbar Strain with Radiculopathy involving Lower Left Extremity	5243	10%	20040824	
			…Lumbar Strain with Radiculopathy involving Lower Left Extremity (Claimed as lower back problem, leg numbness)	7522	0%		
Central Canal Stenosis	Cat II	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Mild Disk Protrusion at L5-S1 (Low Back Pain).  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain condition began in March 2002 after lifting heavy plumbing equipment at work.  He had initial improvement with physical therapy and Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)). Lumbar spine X-rays were normal in May 2002, while magnetic resonance imaging on 29 January 2003 demonstrated L3-4 and L5-S1 right paracentral disc herniations that encroached on exiting nerve roots of L3-4 and touched the traversing right S1 nerve root.  Pain worsened after he discontinued physical therapy.  In March 2003 the CI rated the pain at 4-5/10 (10 being the worst pain) on a daily basis, which was exacerbated with prolonged standing, lifting, bending, twisting or running.  He had episodes of lower extremity numbness, which resolved and he denied any lower extremity radicular pain or persistent numbness.  He had no bowel, bladder or sexual dysfunction.  On examination he had difficulty touching his toes.  In May 2003 a physical therapist noted the CI’s back range of motion (BROM) was 20 degrees flexion and extension 15 degrees.  Treatment consisted of Celebrex (celecoxib, an NSAID) and Flexeril (cyclobenzaprine, a muscle relaxer).  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 an MEB.  The MEB forwarded “central canal stenosis” and “mild disk protrusion at L5-S1” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated June 2003, 6 months prior to separation, the CI reported he injured his back while deployed.  Physical examination showed mild tenderness to palpation at L4/L5.  At the NARSUM examination dated 19 June 2003, 7 months prior to separation, the CI was able to heel and toe walk.  He had good range of motion (ROM) of his back.  He had a negative straight-leg raising both in the sitting and supine positions and had symmetric muscle tone and bulk.  Neurological evaluation was unremarkable.  Patrick’s maneuver [to determine sacroiliac or hip pathology] was negative.  The CI had mild paraspinal muscle tenderness over the right posterior iliac crest.  In September 2003 the CI reported he continued to have low back pain, had no improvement with an epidural steroid injection, but did have improvement with physical therapy.  He had full strength of both lower extremities.  Flexion was limited to 90 degrees and extension to 20 degrees.  

At the VA Compensation and Pension (C&P) examination in August 2004, performed 8 months after separation, the CI reported constant pain at the lower back described as squeezing, aching, oppressing and sharp in nature with a severity of 7/10 (10 being the worst pain), which was elicited by physical activity and relieved by rest.  His condition did not cause incapacitation. Physical examination revealed complaints of radiating pain on movement down the left leg to below the knee.  Muscle spasm and tenderness were present in the lumbar paraspinal region.  Straight leg raising was negative on the right and positive on the left.  The ROM measurements are in the chart below and the ROM of the spine was additionally limited by pain, fatigue, weakness, and lack of endurance, but not by incoordination.  There was no ankylosis.  The CI had no bowel or bladder dysfunction, although he reported erectile dysfunction.  A lumbosacral spine series was negative in August 2004.  However, an MRI in November 2004, 11 months post-separation, demonstrated a broad based disc protrusion encroaching on both L4 emerging nerve roots and thecal sac.  Additionally, there was moderate to severe spinal canal stenosis and irregularity of the L3 posterior inferior vertebral body margin suggestive of a chronic avulsion fracture versus an osteophyte and there was also a broad based disc protrusion contiguous with both exiting L5 nerve roots and emerging right S1 nerve root.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% coded 5295 (lumbosacral strain), citing mild disk protrusion at L5-S1 as the Category I unfitting condition. The PEB determined that central canal stenosis was a Category II condition that contributed to and was related to the unfitting condition.  The VA assigned a 10% rating using the 5243 code (intervertebral disc syndrome) based on the VA C&P examination 8 months after separation, citing lumbar strain with radiculopathy involving the lower left extremity.  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) reported on the neurological examination 4 months prior to separation.  Board members also noted that a physical therapy examination 3 days earlier noted the BROM (back ROM) flexion was 25 degrees, which was disparate with the proximate MEB examinations and subsequent neurological and VA examinations.  Although there was muscle spasm noted at the PT and VA examinations, there was no report of an abnormal gait or spinal contour; thus, the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  MRI studies supported some level of radicular involvement, but physical examinations proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore, the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness or sensory impairment existed to any degree that could be described as functionally impairing.  Therefore, the Board concluded that an additional disability rating was not justified on this basis.  

Board members then discussed the Category II central canal stenosis condition and determined it contributed to and was related the Category I mild disk protrusion at L5-S1 (low back pain) condition based on imaging findings; therefore, it was neither separately unfitting nor compensable IAW VASRD §4.14 (avoidance of pyramiding).  

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 mild disc protrusion at L5-S1 (low back pain) condition.  

BOARD FINDINGS:  In the matter of the Navy Category I mild disc protrusion at L5-S1 (low 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.  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 20140804, 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 22 Sep 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:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN