RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00117
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040922

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aviation Support Equipment Technician, medically separated for “degenerative disk disease of L5-S1” with a disability rating of 20%.

CI CONTENTION:  The CI requests reconsideration of the PEB rating for his back condition.  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 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 - 20040621	VARD - 20041202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Disk Disease of L5-S1	5243	20%	Lumbar Degenerative Disk Disease with Intervertebral Disc Syndrome	5243	40%	20040720	
			Left Radicular Symptoms Due to Lumbar Degenerative Disk Disease…	8620	10%		
			Right Radicular Symptoms Due to Lumbar Degenerative Disk Disease…	8620	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Degenerative Disk Disease (DDD) of L5-S1.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in March 2002 after receiving spinal anesthesia for a peroneal cyst removal.  The CI initially reported localized low back pain (LBP) with occasional radiation to the right hip, without leg pain.  Lumbar spine X-rays noted minimal osteoarthritis.  Lumbar magnetic resonance imaging (MRI) in October 2002 showed DDD without central spinal canal stenosis or nerve impingement.  At a primary care (PC) visit in February 2003 the CI reported LBP that traveled to both legs, right more than left, to the knee, with occasional sharp pain and paresthesia to the right foot.  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 first MEB dated 27 February 2003, forwarded “chronic low back pain” for PEB adjudication.  

The initial MEB NARSUM examination also on 27 February 2003, (19 months prior to separation), noted complaints of constant LBP, aggravated by activity, that radiated down the right lower extremity (RLE), with occasional numbness.  Physical examination showed a guarded gait, the left sacroiliac joint was very tender and there was possible locking of the joint.  The left sciatic notch was also tender.  The CI was able to heel and toe walk, but heel walking caused pain.  Lower extremity (LE) sensation was normal.  Straight leg raise testing (SLR) to elicit spinal nerve root tension signs caused pain in both hamstrings at 60 degrees, without increased pain with sciatic stretch.  Provocative maneuvers for SI joint pain were positive on both sides.  The Board recommended four months of additional limited duty and chiropractic treatment and anticipated that at the completion the CI would be fit for full duty.  

The CI reported increased radiating left lower extremity (LLE) pain and repeat lumbar MRI in April 2003 noted DDD and at L5-S1 there was an annular tear (ligament surrounding the disc material) was noted.  There was no evidence of spinal canal stenosis or nerve root compression.  Serial examinations in record noted normal strength, sensation and reflexes of both LE.  At a PC visit in June 2003, the CI had full range of motion (ROM) with minimal tenderness and normal strength and he was determined to be fit for full duty.  After return to full duty, in December 2003 the CI reported non-radiating LBP and his exam showed full ROM and negative SLR and the orthopedic recommendation was an administrative separation since the CI was found fit for duty, but not fit for sea duty.  

In January 2004 the CI reported LBP and RLE pain and repeat MRI was unchanged.  In March 2004, the CI underwent discography (injection into disc to reproduce pain) and the procedure produced pain at L5-S1.  A second MEB, conducted on 23 March 2004, forwarded “degenerative disk disease of L5-S1” for PEB adjudication.  At the MEB NARSUM examination on 24 March 2004 (6 months prior to separation), the CI complained of continued LBP.  On examination, there was tenderness of the lumbar region and LE strength and sensation were normal.  The NARSUM noted that pain management (PM) was planning to perform an electrothermic disc procedure.  A MEB NARSUM addendum, dated 7 April 2004, (6 months prior to separation) noted continued complaints of LBP.  Examination revealed no motor or sensory deficit, but SLR was positive on the right.  The CI had undergone the electrothermy procedure by PM a week earlier and was to start physical therapy (PT).  At an orthopedic clinic examination on 18 May 2004, the CI stated his LBP was decreasing.  Physical examination showed normal muscle and sensory assessments.  The lumbar ROM is listed in the chart below.  At a PT clinic visit, on 7 June 2004, the CI reported increased LBP since he stopped wearing a back brace.  Examination showed decreased ROM (see chart below) without muscle spasm.  At follow-up visits the CI reported LBP and episodes of intermittent LLE radiation and notes indicated the CI reported continued improvement in his pain with PT.  Radiographic imaging [X-ray], in July 2004, showed an unremarkable lumbar spine.  

At the 20 July 2004 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported constant LBP that radiated down both LE at times.  At the examination the CI reported pain in his RLE and the examiner indicated a sensory distribution of L3-4.  The CI described incapacitation 25 times per year, with 19 incapacitating episodes over the last year, but the examiner noted the total number of days was not specified.  The CI reported wearing a back brace for 3 hours per day.  Physical examination showed a normal posture and gait; and no muscle spasm, tenderness or radiating pain.  Examination tests for radicular signs were negative.  Back ROM is listed in the chart below and ROM movements were limited by pain.  The CI had normal strength, sensation, and reflexes.  A second VA C&P evaluation, dated 21 March 2005, was performed 6 months after separation to evaluate additional claims for service connection and was not focused on the back condition.  The physical examination revealed a normal posture and gait, although the CI was using a wheelchair, pushed by a relative.  Back ROM measurements are displayed in the chart below.  There was no pain with motion and there was no additional loss of ROM with repetition.  The CI displayed normal motor and sensory functioning.  ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	Ortho ~4 Mos. Pre-Sep
	PT~4 Mos. Pre-Sep
	VA ~2 Mos. Pre-Sep
	VA ~6 Mos. Post-Sep
	
Flexion (90 Normal)	60	50	30	90	
Combined (240)		190	150	240	
Comments			Pain		
§4.71a Rating	20%	20%	40%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The initial PEB, dated 20 May 2004, found the CI fit for continued active duty.  The CI appealed and requested a Reconsideration PEB and he requested a medical discharge with 20% rating.  The PEB dated 21 June 2004 rated the DDD of L5-S1 condition 20%, coded 5243 (intervertebral disc syndrome).  The VA rated the DDD of L5-S1 condition 40% coded 5243, based on the VA C&P examination 2 months before separation, citing forward flexion limited to 30 degrees.  Additionally, the VA rated right and left radiculopathy at 10% each, coded 8620 (sciatic nerve neuritis).  A subsequent VA rating decision, 6 months after separation, continued the 40% lumbar condition and 10% (each) left and right radicular ratings. 

The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees), reported on the orthopedic and physical therapy examinations.  The Board noted that the service examinations supported a 20% rating while the pre-separation VA examination supported a 40% rating based on limitation of motion.  In assigning probative value to these somewhat conflicting examinations, the Board noted the examinations by orthopedics and physical therapy were consistent with the diagnostic and clinical pathology in evidence in the STR (full to moderately limited ROM, consistent observations of normal gait, no muscle spasm).  The July 2004, VA examination recorded forward flexion and extension stopped where pain began, and it was not clear to the Board if the CI could move beyond this point or not.  Additionally, another C&P examination performed 6 months after separation noted full, painless back ROM.  Therefore, the Board concluded that the pre-separation C&P examination finding of 30 degrees of flexion, the sole piece of ROM evidence supporting a 40% rating in record, held less probative value for the Board’s rating recommendation.  The Board determined that the disability picture conveyed by the total evidence was consistent with a 20% rating.  The CI was noted to have LBP due to sacroiliac dysfunction and lumbar degenerative disc disease.  The Board’s rating recommendation is for the LBP and sacroiliac dysfunction together IAW VASRD §4.66 (sacroiliac joint) which stipulates “The lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes.”

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 (IVDS).  Although the CI had intervertebral disc disease there were no documented incapacitating episodes requiring physician-prescribed bed rest in  record to warrant consideration of rating under the alternate VASRD formula (for IVDS).  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 DDD of L5-S1 condition.

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI experienced radiating pain to both legs in the course of treatment.  However, all exams noted normal strength and sensation of the lower extremities.  While the CI 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 impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an additional disability rating was not justified on this basis.  

BOARD FINDINGS:  In the matter of the DDD of L5-S1 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 20150202, 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 20 Oct 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:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

						  XXXXXXXXXXXXXXXXXX	     				  			  		  Assistant General Counsel
						  (Manpower & Reserve Affairs)