RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE: pd-2015-02036
BRANCH OF SERVICE:  NAVY	SEPARATION DATE:  20040419

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Engineering Aid, medically separated for “degenerative disk disease [DDD]” with a disability rating of 10%.  

CI CONTENTION:  The CI contends that his back condition has worsened.  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 - 20040112	VARD – 20040810	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain	5295	10%	DDD, Lumbosacral Spine	5243	10%	2004210	
Degenerative Disk Disease	Category II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Low Back.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in approximately 1998 with insidious onset.  Radiographic imaging revealed bilateral L5 pars defect (stress fracture or spondylolysis); and several levels of DDD.  The 15 October 2003 MEB NARSUM examination, 6 months prior to separation, noted complaints of back pain without radicular pain which was aggravated with lying down, prolonged standing, lifting and bending over.  The CI denied any numbness or tingling.  Physical examination showed a normal gait and the ability to heel/toe and tandem walk.  Sensation and motor strength testing were normal.  “He had minimal pain with forward flexion at the waist…full extension causes no symptoms.”  
At the 10 February 2004 VA Compensation and Pension (C&P) evaluation, 2 months prior to separation, the CI reported chronic back pain.  Physical examination revealed a normal posture, gait, and heel-toe tandem walk.  During range of motion (ROM) testing the CI had a flexion of 80 degrees (normal 90) and combined ROM of 215 degrees (normal 240); painful motion was present with repetitive ROM.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5295 (lumbosacral strain).  The PEB also listed DDD as a related diagnosis (Category II) that contributed to the back condition.  The panel agreed that the DDD was a diagnosis related to the low back pain Category I unfitting condition and was not a separate condition which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA also rated the back condition 10%, coded 5243 (intervertebral disc syndrome), based on the C&P evaluation 2 months prior to separation, citing slight spinal tenderness and limitation of motion.  

The PEB utilized the older 5295 VASRD spine coding/criteria; code 5295 was revised and replaced by code 5237 (lumbosacral strain) effective 26 September 2003.  However, IAW DoDI 6040.44, this panel is required to recommend a rating IAW the VASRD in effect at the time of separation which is the 2004 VASRD (the same as the current general spine rules).  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees, as reported on the detailed pre-separation VA examination.  There was no muscle spasm or guarding severe enough to result in 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 with incapacitating episodes which would provide for a higher rating under that formula.  

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’s 10% adjudication for the back condition.  Although a change in coding to 5237 or more accurately 5243 would correct the record, it is unnecessary because there is no recommended change to the PEB rating.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB 10% adjudication.  There are 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 20150723 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

      In accordance with reference (a), I have reviewed the cases listed below 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:

		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN

		
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	     				  Acting