RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02150
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20080614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Builder Constructionman, medically separated for overall effect due to “lumbar back pain,” “Scheuermann’s disease” and “thoracic back pain” with a disability rating of 0%.

CI CONTENTION:  He was found unfit based on a hereditary condition that did not run in his family and was later told by a physician that he did not have the condition.  The physician found a bulged disc in his lower back and told him he had degenerative disc disease.  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 - 20080509	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Overall Effect due to Lumbar Back Pain, Scheuermann’s Disease and Thoracic Back Pain	None	0%	No VA Examination in Evidence Proximate to Separation	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Lumbar Back Pain, Scheuermann’s Disease, Thoracic Back Pain.  The PEB combined the three listed conditions under a single disability rating for “overall effect” as permitted by DoDI 1332.38 (E3.P3.4.4).  The combination of multiple conditions as a single disability reflects the PEB’s determination that each condition was not separately unfit, but the functional impairment resulting from the conditions when considered together was unfitting.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s single overall effect rating was justified in lieu of separate unfit determinations and ratings.  If the panel judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was unfitting in and of itself as shown by a preponderance of evidence.  The panel’s recommendations may not produce a lower combined rating than that of the PEB.  

Panel members noted that the three conditions listed by the PEB as contributing to unfitness were all thoracolumbar back conditions, and could not be separately rated without violating VASRD §4.14 (avoidance of pyramiding).  Therefore, the panel accepted the PEB finding that the CI was unfit for a thoracolumbar spine pain condition, and focused on determining the appropriate coding and rating based on the CI’s symptomatology.  

According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in April 2006 after arrival at basic training, with a gradual onset of low to middle back pain that was not linked to any specific injury or trauma.  X-ray studies on 7 September 2006 revealed mildly decreased height of multiple mid-thoracic vertebral bodies often seen with Scheuermann’s disease, a hereditary condition manifested by excessive curvature of the spine.  At an orthopedic spine visit on 25 September 2006, the examiner noted no tenderness about the thoracic or lumbar spine and full range of motion (ROM), with moderate pain on extension and none with forward flexion.  An MRI conducted on 6 October 2006 showed an increase in the normal dorsal kyphotic curve of the thoracic spine, severe degenerative disc changes at T7-8, moderate changes at T6-7, and mild degenerative disc changes at T5-6 and T8-9.  The CI was placed on limited duty and was treated with anti-inflammatories, muscle relaxants, epidural steroid injections and physical therapy (PT) without resolution of his lower and mid-back pain.  

At a 20 August 2007 orthopedic clinic appointment, the CI described his mid-back pain as aching and lower back pain as stabbing.  Physical examination showed a stiff gait, no abnormal lordosis or scoliosis (abnormal spinal curvature), and no tenderness to palpation.  ROM showed full extension, side-bending, and side rotation, with flexion described as “6 inches from touching his toes.”  The CI was determined not to be a surgical candidate.  At PT evaluations on 5 September 2007, 30 October 2007 and 20 December 2007, recorded lumbosacral ROM measurements were: 16 degrees of flexion (normal 90) and between 3 and 7 degrees of extension (normal 30).  

At an 18 December 2007 pain management examination, the CI reported non-radiating back pain that was exacerbated primarily by lifting.  The examiner reported normal lordotic curvature of the lumbar spine and a normal gait with no spasms observed.  Lumbar ROM was full and pain- free except for movement to extension.  Lumbar X-rays taken that day (not in evidence) showed degenerative disc disease at L5-S1 with facet arthrosis.  

The 14 February 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of ongoing mid to lower back pain.  The NARSUM author referenced earlier physical examinations in summarizing the CI’s physical condition; it did not appear a separate assessment was conducted at time of NARSUM preparation.  During the 6 March 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the examiner reported tenderness at L4-S1 and reduced ROM with flexion, extension, and lateral bending, but specific measurements were not provided.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB provided a combined rating of 0% without VASRD coding, determining that the CI did not have a single unfitting condition but that the overall effect of three related conditions rendered him unfit.  As mentioned above, panel members agreed the CI was unfit for duty based on pain in the thoracic and lumbar spine regions, and that the appropriate rating for this condition must be derived from the VASRD General Rating Formula for Diseases and Injuries of the Spine.  

The MEB referred thoracic and lumbar spine conditions separately, however, conditions of the thoracic and lumbar spine are considered as one anatomic segment for rating purposes.  After thoroughly reviewing the evidence, the panel agreed that the 18 December 2007 examination (latest evaluation performed prior to separation) and the 20 August 2007 orthopedic assessment, that was referred to and relied upon by the NARSUM author, provided the greatest probative value for rating, with the recorded ROM measurements consistent with the clinical pathology of the condition and conducted by physicians.  Members also noted they were consistent with the examination conducted on 25 September 2006 by the orthopedic spine surgeon.  After considering all the evidence, panel members agreed that a 10% rating, coded 5242 (degenerative arthritis of the spine), was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees).  The 18 December 2007 examination showed full ROM, but also supported a 10% rating based on painful motion.  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, and 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 recommends a disability rating of 10% for the back condition, coded 5242. 

BOARD FINDINGS:  In the matter of the combined back pain condition, the panel unanimously recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Lumbar Back Pain, Scheuermann’s Disease, Thoracic Back Pain	5242	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150712, w/atchs
Exhibit B.  Service Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		     COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	 (b) PDBR ltr dtd 23 Jan 18 ICO XXXXXXXXXXXXXXXXXX 
	 (c) PDBR ltr dtd 23 Jan 18 ICO XXXXXXXXXXXXXXXXXX
	 (d) PDBR ltr dtd 23 Jan 18 ICO XXXXXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 10 Jan 18 ICO XXXXXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 23 Jan 18 ICO XXXXXXXXXXXXXXXXXX
	 (g) PDBR ltr dtd 23 Jan 18 ICO XXXXXXXXXXXXXXXXXX    
	 (h) PDBR ltr dtd 10 Jan 18 ICO XXXXXXXXXXXXXXXXXX
	 (i) PDBR ltr dtd 10 Jan 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

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

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

     e. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.
 
     f. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge. 

     g. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 0 percent) effective date of discharge.
    
2.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                              	XXXXXXXXXXXXXXXXXX
                              	Acting