RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01397
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20021120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Ammunition Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20020906	VARD - 20021218	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5295	10%	Degenerative Disc Disease, Lumbar Spine, L5-S1, Status Post Discectomy	5299-5295	10%	20021001	
			Scar, Lumbosacral Spine, Residual, to Surgery 	7805	0%	20021001	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Low Back Pain (LBP).  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent micro discectomy surgery in September 2001 for a disc protrusion at L5-S1 with evidence of spinal stenosis.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.

The 12 June 2002 MEB NARSUM examination, 5 months prior to separation, noted complaints of constant left buttock and leg pain with numbness of the entire leg.  Physical examination showed negative straight leg raising testing (for radiculopathy), no Waddell’s signs (patient shows pain not related to range of motion (ROM) testing), a well healed surgical scar, and pain limitation of motion (measurements not cited).

At the 10 July 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported intermittent pain down the back of both legs, weakness and numbness to the anterior aspect of the left thigh.  Physical examination showed a normal gait and posture.  Lower extremity strength and sensory examinations were normal.  The straight leg raising test (for radiculopathy) was negative.  The active ROM was painful with flexion (measurements not cited) which included one positive Waddell’s sign.  The examiner noted that the CI had a normal electromyogram in April 2002.

At the 1 October 2002 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported developing lower back pain in 1999 when he fell on his back.  He complained of constant low back pain with numbness and tingling going into his left leg aggravated with normal activity.  He had had difficulty walking, bending and standing.  Physical examination showed a slow gait, but posture was not addressed.  The straight leg raising test was positive.  ROM was flexion to 85 degrees (normal 90) and combined ROM was 235 degrees (normal 240) with painful motion.  Repetitive ROM resulted in fatigability and increased pain but ROM loss was not addressed.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain condition 10%, analogously coded 5299-5295 (lumbosacral strain), citing no neurologic or electrodiagnostic abnormality.  The VA also rated the low back pain condition 10%, also coded 5299-5295, based on the C&P examination 2 months before separation, citing painful motion.  The VA also rated the back surgical scar 0%, coded 7805 (other scars), citing residual to lumbosacral spine surgery.

Under the 2003 VASRD spine rules in effect at the time of separation, the CI’s low back pain condition met criteria for a rating of 10% and not higher.  There was no documented evidence of muscle spasm on extreme forward bending in a standing position and/or loss of unilateral lateral spine motion under 5295.  Additionally, there was no performance-based evidence from the record that the back surgical scar significantly interfered with satisfactory duty performance at separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back pain condition.

BOARD FINDINGS:  In the matter of the 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 panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, 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 10 May 17

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and 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 USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

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