RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01247
BRANCH OF SERVICE:  NAVY	SEPARATION DATE:  20040630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, F/A-18 Systems Organizational Initial Maintenance Technician, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  No specific contention was made.  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.  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 - 20040324	VARD - 20040823	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Degenerative Disc Disease, Lumbar Spine	5242	20%	20040616	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in 1996 without antecedent injury or trauma.  The LBP began to interfere with duty in 2001.  An MRI on 1 October 2001 revealed an L4-5 degenerative disc and an L5-S1 disc herniation.  In 2002, the CI received several epidural steroid injections which resulted in pain relief.  The 28 October 2002 physical therapy evaluation, 19 months prior to separation, revealed a normal gait and lumbar range of motion (ROM).  

The 8 January 2003 MEB NARSUM, 18 months prior to separation, noted a normal neurological examination and flexion was full (to toe-touch, normal 90 degrees).  In primary care 2 months later and again on 6 November 2003, the CI was noted to have a normal gait.  A second MEB NARSUM examination on 19 November 2003, 7 months prior to separation, recorded persistent LBP.  Physical examination showed spinal tenderness and full ROM; painful motion was not addressed.  The neurologic examination was normal.  During the 12 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the physical examination showed full ROM and again, painful motion was not addressed.  Provocative testing for nerve root irritation was negative.  The neurological examination was normal.  

At the 16 June 2004 VA Compensation and Pension (C&P) evaluation, 2 weeks before separation, the CI reported constant LBP which radiated to the left leg.  He reported 15 days of incapacitating episodes due to the LBP however this claim was not supported by the record.  Physical examination showed normal gait and posture, with a low back muscle spasm but no spinal tenderness.  Flexion was 50 degrees and combined ROM was 190 degrees; painful motion was noted.  The panel observed flexion, extension, and rotation ROM were limited due to pain.  Radiating pain was not reported and provocative nerve root irritation for radiculopathy was negative.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5237 (lumbosacral strain).  The VA rated the LBP condition at 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 2 weeks before separation, citing limitation of flexion.  The panel agreed there was not a limitation of spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine, as recorded by the MEB and MEB NARSUM examinations and corroborated by the totality of the STR evidence.  There was, however, spinal tenderness to support a 10% rating as recorded on the MEB NARSUM 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. No incapacitating episodes requiring physician-prescribed bed rest were found in the STR to warrant consideration of rating under that alternate VASRD formula.  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 LBP condition.

BOARD FINDINGS:  In the matter of the chronic LBP 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.  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, dated 20160927, 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 USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN