DEPARTMENT  OF  THE  NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309 WASHINGTON NAVY YARD, DC 20374

IN   REPLY  REFER   TO:
1850
CORB:003
20 Feb 20

From: To:

Subj: Ref:

Director, Secretary of the Navy Council of Review Boards PD-2017-00015

PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

(a) DoDI 6040.44
(b)	PDBR ltr dtd 27 Sep 18

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy.

2.	On 12 February 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXX	CASE: PD-2017-00015
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20040619

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Information Systems Technician, medically separated for “mechanical back pain centered around the thoracic spine” with a disability rating of 20%.

CI CONTENTION:  “Review all conditions.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20031222	VARD - 20061122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Back Pain…	5299-5295	20%	
Scoliosis of the Thoracolumbar Spine	
5237	
10%	
20050118	
Myofascial Pain Syndrome	Cat II					
Idiopathic Scoliosis	Cat II					
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Mechanical Back Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back pain began in 2000 after entering active duty. At her military enlistment physical in 2000, thoracolumbar scoliosis of 10-20 degrees was noted, but she denied symptoms. She then developed mid back pain, aggravated by activities, especially running. A scoliosis survey on 13 September 2001 and orthopedic evaluation on 11 October 2001 indicated the degree of the CI’s scoliosis was not responsible for her back pain and diagnosed mechanical back and myofascial pain.  Physical therapy and chiropractic treatment provided no relief.

The 20 May 2003 MEB NARSUM examination, 13 months prior to separation, noted CI complaints of pain in the area of the thoracic spine and surrounding muscles. Physical examination revealed mild thoracic scoliosis to the right and mild paraspinal muscle tenderness. At a primary care clinic appointment on 24 September 2004, 3 months after separation, the CI reported chronic, intermittent back pain. On examination, she walked with a normal gait and had “good” thoracic and lumbar spine range of motion (ROM).

At the 18 January 2005 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported intermittent, dull back pain, rated at 3/10, with no radiation. Physical examination showed minimal scoliosis and good muscle tone without any spasm, atrophy, or tenderness. There was no evidence of incoordination, weakness or fatigability. Thoracolumbar ROM measurements, in degrees, were flexion of 80 (normal 90) and combined ROM of 230 (normal 240), without any complaint of pain.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 20%, analogously coded 5295 (lumbosacral strain). The VA rated the low back condition 10%, coded 5237 (lumbosacral or cervical strain), based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. The PEB utilized a VASRD code that was no longer in use by the date of the CI’s separation, and DoDI 6040.44 requires the panel to recommend a rating IAW the VASRD in effect at the time of separation. Members agreed that a 10% rating was justified for tenderness noted at the MEB NARSUM examination, and limitation of flexion and combined ROM (greater than 120 degrees but not greater than 235 degrees) documented at the VA 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. There was also no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula. While the panel concluded a 10% rating was supported based on VASRD rating criteria in effect at the time of separation, a rating lower than that adjudicated by the PEB may not be recommended IAW DoDI 6040.44, and therefore no change to the PEB’s coding choice or rating is recommended. After due deliberation, considering all 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 low back condition.

BOARD FINDINGS: In the matter of the mechanical back pain and IAW VASRD §4.71a, the panel 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 20161206, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record	

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