RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01097
BRANCH OF SERVICE:  marine corps 	SEPARATION DATE:  20040831

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E1, Basic Marine, medically separated for “T12 and L1 superior end plate fractures” with a disability rating of 10%.   

CI CONTENTION:  Her condition has worsened with time and continues to negatively impact her daily activities.  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 - 20040712	VARD - 20050311	
Condition	Code	Rating	Condition	Code	Rating	Exam	
T12 & L1…Fractures	5235	10%	Thoracic T12 Fracture	5235	0%	20050125	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

T12 and L1 Fractures.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in May 2004 after a fall.  Radiographic studies showed compression fractures in the thoracic (T12) and lumbar (L1) spines with no impingement of nerve structures.  The 7 June 2004 MEB NARSUM examination, 3 months prior to separation, recorded a gait without a limp.  The back was tender and exhibited “minimal” spasm. Range of motion (ROM) was recorded as flexion to the lower shins (equivalent to ~70-80 degrees; normal 90) with “mild discomfort.”  No other planes of motion were recorded, but the examiner noted “mild discomfort” with back extension.  The 23 June 2004 MEB examination (recorded on DD Forms 2807-1 and 2808) showed a normal gait.  The examiner noted tenderness in the lower back with full flexion and extension decreased by 10 degrees (normal 30).  
At the orthopedic clinic appointment on 9 July 2004, 2 months prior to separation, the CI reported periodic pain with lifting.  On examination, there was no tenderness.  The examiner noted full ROM and an absence of pain and tenderness.  

At the 25 January 2005 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported non-radiating low back pain. The CI was not taking medications and was not under the care of a physician for back pain.  Physical examination showed normal posture, stance and gait.  ROM was recorded as flexion to 90 degrees (normal) and combined ROM of 240 degrees (normal), without objective evidence of painful motion, spasm, weakness or tenderness.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5235 (vertebral fracture or dislocation).The VA rated the back condition 0%, also coded 5235, based on the C&P examination 5 months after separation.  Although there was insufficient limitation of motion to support a 10% rating, the panel agreed a 10% rating was justified for the presence of tenderness and spasm not resulting in an abnormal gait or spinal contour as noted on the MEB NARSUM and physical examinations.  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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

BOARD FINDINGS:  In the matter of the T12 and L1 superior end plate fractures 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.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, undated, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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 USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN

		
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	     				                                Acting