RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02573
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20051117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Storekeeper, medically separated for “chronic lumbosacral back pain” with a disability rating of 20%.  

CI CONTENTION:  Back condition and “rape was not included but was confirmed.”  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 - 20051007	VARD - 20060419	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lumbosacral Back Pain	5237-8520	20%	Low Back Strain	5237	NSC	20051017	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Chronic Lumbosacral Back Pain.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in May 2003 after being slammed against a broken ladder.  An 11 June 2003 primary care note recorded that the CI had osteoporosis (bone loss) and was pain-free, but did not mention the back injury.  She started physical therapy (PT) for osteoporosis on 16 June 2003, and on examination, her motor function was normal as was lumbar spine range of motion (ROM); the examiner noted that she worked in supply with no difficulty.  At a 17 October 2003 primary care visit, the CI reported a 6-month history of low back pain (LBP) and stated that she not disclosed this earlier because she hoped to become an officer.  The provider observed her to be in no acute distress but did not perform a physical examination.  
On 6 January 2004, the CI complained of progressive LBP and was tender over the left sacroiliac (SI) joint (between the lower spine and pelvis).  X-rays of the SI joint were normal.  At a mental health appointment for an unrelated condition, her neurological examination was “grossly intact.”  During an orthopedics visit on 22 March 2004, the CI reported that she almost fell off a ladder in May of 2003 (first mention in the STR of a fall).  She had pain in the lower back which radiated down the left leg; sacral area tenderness was present.  ROM measurements were flexion to 90 degrees (normal), lateral bending to 30 degrees (normal) and “hyperextension” to 10 degrees, but with pain.  Neurological examination was normal and provocative testing for nerve root irritation was negative.  A bone scan showed some increased uptake near S1 but the significance of this was “inconclusive.”  Lumbar spine and SI joint X-rays were unremarkable as was a computed tomography (CT) scan 4 days later.  

In physical therapy on 16 November 2004, the CI said she had been slammed against a ladder when it shifted while moving a box.  She reported progressive pain and that her left leg gave out leading to four falls.  On examination, pain behavior was observed, and the left hip was elevated compared to the right.  Flexion was to 90 degrees, but the back remained flat and deviated to the left with motion.  Extension was limited to 20 degrees (normal 30) by pain.  The left SI joint was exquisitely tender and the L5 vertebra moderately tender.  Weakness was present in the left lower extremity (LLE) from the hip to the great toe, but reflexes were normal.  A 1-2 beat clonus (abnormal muscle beat usually indicative of injury above the spinal cord) was present on the left.  

The 4 December 2004 MEB physical examination (recorded on DD Form 2808), showed decreased LLE strength and positive straight leg raise (SLR) testing on the left for radiculopathy.  ROM measurements showed flexion to 90 degrees and extension to 10 degrees.  Provocative testing for nerve root irritation produced pain in the lower back but not the legs.  There was left SI joint pain with lateral rotation, and normal reflexes bilaterally.  Lumbosacral spine and sacrum X-rays the same day were normal.  

At a 27 May 2005 occupational health clinic appointment, 6 months prior to separation, the CI was seen for her monthly line of duty (LOD) evaluation.  Physical examination revealed tenderness over the SI joint area, normal reflexes, and positive SLR testing on the left.  ROM measurements showed flexion to approximately 40 degrees and a combined ROM of approximately 115 degrees.  Sensory and motor examinations were not recorded.  A 23 June 2005 occupational health visit mirrored the examination 1 month earlier.  

The 30 June 2005 MEB NARSUM examination, 5 months before separation, was accomplished by an orthopedic surgeon.  The CI reported constant back as well as left leg pain with numbness/tingling and frequent giving away.  She could not stand for more than 15 minutes without significant pain.    Physical examination showed diffuse tenderness from L5 down through the sacrum and over the SI joints.  Lumbosacral (not thoracolumbar) ROM measurements showed flexion to 60 degrees and a combined ROM of 170 degrees.  Pain was observed in the lumbosacral region during SLR testing, but not in the left leg.  Sensation was normal and LLE weakness was present.  Reflexes were symmetric and clonus was absent.  The examiner reported that “X-rays of the lumbosacral spine and sacrum today show no abnormalities.”  

At the 17 October 2005 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported constant, sharp back pain since a broken ladder slammed into her back.  Physical examination revealed upright posture and normal gait despite use of a cane.  She could not heel-toe walk and stated she was unable to lift her left leg; the examiner recorded that “she appears to have a positive straight leg raise on the left at 30 degrees.”  There was tenderness over the lower lumbar spine with spasm of the paraspinal muscles.  ROM measurements showed lumbar spine flexion to 60 degrees and a combined ROM of 185 degrees.  There was no additional loss of motion, pain, fatigue, weakness, or lack of endurance with repetitive lumbar spine motion.  There was decreased LLE strength and neurologic examination again showed a normal gait as well as stance, and normal reflexes and sensation.  On 28 November 2005, LLE electrodiagnostic testing was normal.  Incapacitation was not documented in the STR.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, dual coded 5237-8520 (lumbosacral strain-paralysis of the sciatic nerve).  The VA did not service connect the back condition, coded 5237 (lumbosacral strain), citing no evidence that the injury occurred in service.  The panel agreed that a 20% rating, but no higher, was supported by limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on the occupational evaluations.  The MEB NARSUM and VA examinations noted that flexion was limited to 60 degrees, but this was for the lumbar rather than the thoracolumbar spine. Incapacitation was not recorded, and while some examinations documented weakness, this was in the wider context of the LLE, which is not consistent with a radicular process.  Neurological evaluations throughout the STR were within normal limits as were X-rays and electrodiagnostic testing.  The panel agreed there was no evidence to support a rating higher than that adjudicated by the PEB.  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 chronic lumbosacral back pain condition.  

BOARD FINDINGS:  In the matter of the chronic lumbosacral back pain 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 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 201561112, 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 USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
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	     				     Acting