RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02223
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040602

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Seaman Storekeeper, medically separated for “degenerative disc disease L5-S1” with a disability rating of 10%.  

CI CONTENTION:  The CI contends that his condition has worsened and requests a panel review.  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 - 20040202	VARD - 20040528	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Disc Disease, L5-S1	5295	10%	Degenerative Disc Disease, L5-S1	5243	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Degenerative Disc Disease, L5-S1.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain (LBP) condition began in December 2001.  The CI denied any specific injury or trauma.  Magnetic resonance imaging (MRI) studies showed a small central and left paramedian protrusion at L5-S1 without encroachment on the nerves.  Evaluation by orthopedics, 24 September 2002 concluded with a diagnosis of L5-S1 disc protrusion without actual disc herniation, pain radiating down to his left buttocks, and recommended non-surgical treatment to include potential pain clinic treatment.  The CI was treated in March 2003 with three epidural steroid injections that resolved his lower left extremity radicular pain; however, he then began experiencing radiating pain in his right lower extremity.  He underwent a discogram on 30 May 2003 which did not show significant disc disease.  

The 27 October 2003 MEB NARSUM examination, 7 months prior to separation, noted complaints of LBP which caused the CI not to be able to lift more than 10 lbs.  Pain was aggravated by running, prolonged standing or walking.  Examination noted tenderness to palpation, decreased sensation in the left lower extremity in a non-dermatomal distribution.  His motor strength testing was 5/5 throughout. He had negative straight leg, FABER and log roll tests.  There was only 1 range of motion (ROM) examination in evidence which the panel weighed in arriving at its rating recommendation.  The examiner noted flexion as “two inches from the floor” (which would approximate 85 degrees of forward flexion) and extension to 5 degrees.  There was no mention of spasm or guarding or an altered gait.  

The CI did not attend a VA Compensation and Pension (C&P) evaluation proximate to separation. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “degenerative disc disease, L5-S1” condition 10%, coded 5295 (lumbosacral strain), citing restricted ROM.  The VA rated the “degenerative disc disease, L5-S1” condition 10% coded 5243 (intervertebral disc syndrome) citing painful motion and functional impairment based on the STR.  The panel agreed that a rating of 10%, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) reported on the NARSUM examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour to justify a higher 20% rating.  There was also no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  

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 degenerative disc disease condition.  

BOARD FINDINGS:  In the matter of the degenerative disc disease condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB 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 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

      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:

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

		
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