RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXX	CASE: PD-2017-00154
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20040813

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Barber, medically separated for “lumbar spine SI [sacroiliac] degenerative disc disease [DDD]” and “mild-moderate persistent asthma,” rated 10% each, with a combined 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 - 20040625	VARD – 20041001, 20051021	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Spine/SI DDD	5237	10%	Disc Disease At L5-S1 ...	5242	0%	

20040212
20050822	
Mild-Moderate Persistent Asthma	6602	10%	Asthma and Status Post (S/P) Pulmonary Emboli	6602-6817	60%		
Venous Thromboembolic Disease	
Cat III	
Venous Thromboembolic Disease	
7799-7704	
10%		
Deep Vein Thrombosis						
Hematoma Formation						
Diabetes Mellitus	Cat III	Insulin Resistance	7999-7913	NSC		
Seborrheic Dermatitis, Psoriasis	Cat III	Psoriasis, Dyshidrotic Eczema	7806	0%		
Gastroesophageal Reflux Disease	Cat III	Gastroesophageal Reflux Disease	7399-7346	10%		
Urge Urinary Incontinence	Cat III	Stress Urinary Incontinence	7599-7542	40%		
Thoracic Outlet Syndrome	Cat III	Thoracic Outlet Syndrome	8699-8610	20%		
Exogenous Obesity	Cat III	Exogenous Obesity	9499-9435,	NSC		
Migraine Headaches	Cat III	Migraine Headache	8100	10%		
Right Hip Pain	Cat III	Right Hip Tendonitis	5253	20%		
Sacral Iliac Joint Pain [Right]						
Right Ovarian Cyst	Cat III	S/P Right Salpingo-Oophorectomy	7619	0%		
Restrictive Lung Disease	
Cat III	
No VA Placement	
Degenerative Joint Disease			
High Risk Hypercholesterolemia			
Cervical Spine Spondylosis			
Controlled Hypertension			
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 90%	

ANALYSIS SUMMARY:

Lumbar Spine/Sacroiliac DDD. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI reported an atraumatic onset of low back pain in March 2002. Imaging (serial MRI’s, discogram) demonstrated DDD (L5/SI, variable reports regarding neural impingement). Multiple neurological examinations were normal, with occasional STR entries of mild weakness in some muscle groups due to guarding, but no significant objective findings or functional implications. Surgery was discussed but ultimately deferred. There were provider entries that documented grossly normal range of motion (ROM), some noting painful motion, and there were none that indicated any significant ROM limitation. The only formal thoracolumbar ROM measurements in the STR were from a physical medicine consult of 5 September 2003 (11 months before separation). That examiner recorded flexion to 90 degrees (normal) and combined ROM of 240 degrees (normal), noting painful motion in some planes. There were multiple entries that documented an antalgic gait, but this could not be ascribed to thoracolumbar spasm and guarding, and there was no STR evidence for abnormal spinal contour or incapacitating episodes.

The 12 February 2004 VA Compensation and Pension (C&P) joint examination, 6 months before separation, noted nonspecific (prominently right SI) pain that was aggravated by prolonged standing, bending, stooping, and squatting. The CI reported chronic use of a cane for the previous 4 months following an epidural and SI joint injections. The VA orthopedic examiner did not comment further regarding gait. A general VA C&P examination conducted the same day documented use of a cane and “significant discomfort with walking” attributed to right SI joint pain. At a neurology VA C&P examination, also on the same day, the provider conversely stated, “Cerebellar, gait, and station are normal.” The joint C&P physical examination recorded “mild” tenderness, made no note of spasm, guarding or abnormal spinal contour, and recorded normal neurological findings (corroborated in the neurology C&P examination). Measured ROM was flexion to 90 degrees and combined ROM of 230 degrees (lacking 10 degrees extension), without note of painful motion.

An orthopedic addendum to the MEB NARSUM was dated 8 June 2004, 2 months prior to separation, and documented back pain, rated at 5-7/10, that prohibited physical fitness testing and limited lifting to 10 pounds. The physical examination recorded normal neurological findings without comment regarding gait, lumbar findings, or ROM.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the lumbar spine condition 10%, coded 5237 (lumbar strain). The VA rated the condition 0%, coded 5242 (degenerative arthritis of the spine), based on the above pre- separation joint C&P examination and citing full ROM without pain (erroneous calculation of combined ROM using supernormal values in some planes). Panel members agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported in the C&P examination. Members also agreed that there was satisfactory evidence of painful motion to support a minimum 10% rating IAW VASRD
§4.59. 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 that basis. 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 lumbar spine condition.

Asthma. The CI was diagnosed with asthma in 2003 and continued to experience symptoms, triggered by allergies and exertion, which required intermittent use of albuterol (inhaled bronchodilator). She was also maintained on Singulair (oral bronchodilator) and there was ample STR confirmation of its daily use for an extended period encompassing separation. A pulmonary function test (PFT) in July 2003 recorded an FEV-1 of 89% predicted and an FEV-1/FVC ratio of 90%, and a later PFT in February 2004 (6 months before separation) yielded an FEV-1 of 98% predicted and an FEV-1/FVC ratio of 104% (all measurements post-bronchodilator). There was no STR evidence for respiratory failure, hospital admissions, continuous requirement for systemic corticosteroids, or monthly exacerbations requiring physician visits.

At the C&P general examination, the CI described asthma symptoms that were triggered by environmental allergens and “reasonably controlled” with avoidance of allergens, intermittent albuterol, and daily Singulair. A 31 March 2004 pulmonary addendum to the NARSUM, 5 months prior to separation, stated that the CI’s “asthma remains mild to moderate.” A final 1 June 2004 addendum opined that the symptoms had “significantly worsened” due to restrictive lung disease from worsening obesity (ascribed to worsening spine and other orthopedic limitations).

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the asthma 10%, coded 6602 (asthma, bronchial). The VA, based on the pre-separation C&P examination, combined asthma and residuals of pulmonary embolus (addressed separately below) under code 6602-6817 (asthma rated for pulmonary vascular disease), and rated 60% citing criteria of code 6817. The latter are not applicable to the panel’s recommendation since the PEB-adjudicated unfitting condition was asthma, and there was no service diagnosis of (or evidence for) pulmonary vascular disease. That notwithstanding, none of the multiple 60% criteria of code 6817 (dependent on pathology that was not present) were supported by the evidence. The only possibly applicable 60% criterion is “chronic” pulmonary embolus, and, as below, the CI suffered only a single uncomplicated pulmonary embolus.

Panel members noted that VASRD §4.97 defines both PFT-derived criteria and clinical treatment criteria for rating under code 6602. The criteria for a 10% rating include “FEV-1 of [71-80%] predicted, or; FEV-1/FVC of [71-80%], or; intermittent inhalational or oral bronchodilator therapy.” Those for 30% are “FEV-1 of [56-70%] predicted, or; FEV-1/FVC of [56-70%], or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.” As noted above, the 6602 criteria for a rating higher than 30% were not in evidence. The minimum 10% criteria were not satisfied by the PFT evidence, and the intermittent use of albuterol satisfied

only a 10% criterion; but, members agreed that the 30% criterion of daily oral bronchodilator therapy was satisfied by the use of Singulair as amply supported by the evidence. After due deliberation, considering all the evidence and with deference to reasonable doubt, the panel recommends a 30% rating for the asthma, coded 6602.

Contended PEB Conditions: Venous Thromboembolic Disease (VTED), Subsuming Deep Vein Thrombosis (DVT) and Hematoma (Blood Clot) Formation. The CI underwent a hysterectomy with bladder suspension in September 2001 that was complicated by a post-operative hematoma (retroperitoneal) and DVT. This resulted in a pulmonary embolus (PE) and required a 7-month period of oral anticoagulation and limited duty (LIMDU). There was no recurrence of DVT, PE or other complication requiring additional anticoagulation after this single episode. There was no residual extremity edema or other VASRD-ratable findings for DVT. The CI was diagnosed with mild idiopathic VTED (tendency toward excessive clotting) for which she remained on daily aspirin at the time of separation. Vascular and pulmonary addendums to the NARSUM documented the absence of residual DVT or PE complications of VTED, and LIMDU was lifted. The VTED and associated conditions were not implicated in the commander’s non-medical assessment (NMA).

The CI underwent an initial PEB for VTED on 19 May 2004 and was found fit for duty. This was appealed on the basis of the lumbar and right hip/sacroiliac conditions (see below), and VTED was not addressed in the subsequent NARSUM addendum. There was no evidence for any interim change in the VTED, and it was adjudicated by the final reconsideration PEB as Category III (conditions that are not separately unfitting and do not contribute to the unfitting condition).

The panel directed attention to its recommendation based on the above evidence, with its main charge to assess the fairness of the PEB determination that the VTED and subsumed conditions were appropriately adjudicated as Category III. Panel members agreed that there was no performance-based evidence that these conditions (alone or in combination) interfered with satisfactory duty performance at separation. The CI had been cleared for full duty by the initial PEB, and there was no change in the conditions at the time of the final PEB. Therefore, no change in the final adjudication was justified and no additional disability rating is recommended.

Contended PEB Conditions: Right Hip Pain, Subsuming Right Sacral Iliac Joint (SIJ) Pain. The CI first presented with an atraumatic onset of right hip/SIJ pain in mid-2003 (10 months before separation). She underwent an extensive evaluation without identification of a specific etiology (serial X-rays and MRI were normal), and diagnoses of both hip tendonitis and SIJ dysfunction were entertained. There was also some suspicion of overlap with the lumbar disc disease. The pain did not respond to treatment (including epidural, nerve root, and SIJ injections), and there were multiple STR provider entries that attributed an antalgic gait and use of a cane to the condition. There was ample documentation of significant painful motion and guarded hip ROM, but no formal ROM measurements were recorded.

The pre-separation general and joint C&P examinations documented an antalgic gait and use of a cane due to right SIJ pain as elaborated above for the spine condition. The VA joint examiner diagnosed “right hip ilioinguinal and piriformis tendinitis” as a separate condition with “moderate functional impairment.” Hip ROM measurements were not provided. An initial orthopedic addendum to the NARSUM (2 months after the C&P and preceding the initial PEB) documented “moderate to severe” right hip pain that was exacerbated by standing, and that limited walking to 20 minutes. The physical examination recorded joint tenderness and a “slight limp” without use of a cane. No hip ROM measurements were provided. The final orthopedic addendum (referenced above for the lumbar condition) did not address hip or SIJ pain. The condition was not subject to a LIMDU and was not specifically implicated in the commander’s NMA.

An initial VA rating for the right hip/SIJ condition was deferred to obtain ROM measurements. The C&P examination that provided hip ROM measurements did not occur until 22 August 2005

(just over 12 months after separation). This documented continued gait disturbance and use of a cane, with right hip ROM measurements compromised by guarding. Flexion was recorded as “60 degrees at most” (normal 125), extension as “a few degrees” (normal 20), external rotation as “a few degrees” (normal 45), and adduction as “virtually 0 degrees” (normal 45). There was no comment regarding abduction.

The panel directed attention to its recommendation based on the above evidence, and first addressed whether the right hip/SIJ condition was appropriately adjudicated as not unfitting. For this condition, significant doubt was raised in that regard. There was well corroborated evidence from the service and temporally probative VA evidence (to include that presented with the lumbar condition) that it resulted in a significant gait disturbance and unacceptable functional limitations with ambulation and weight-bearing. Panel dissent was centered on reservations as to whether the condition could be isolated enough from the spine and other orthopedic limitations to conclude that it was separately unfitting without undue speculation. After due deliberation, however, the panel consensus was that the preponderance of evidence indicated that the right hip/SIJ condition was separately unfitting and subject to service disability rating.

With this consensus, the panel turned to deliberation of the appropriate coding and rating recommendation. The overlap of the SIJ pain with both the unfitting lumbar and Category III conditions was acknowledged, but the nature of the PEB condition descriptions and adjudications mandated that it be addressed in separate recommendations. The lumbar rating under §4.71a spine criteria was unaffected by the SI component, however, and the panel was careful not to violate VASRD §4.14 (avoidance of pyramiding).

It was noted that the probative value of the only measured ROM evidence (C&P examination ~12 months after separation) was mitigated by its temporal distance from separation, but members agreed that it was reasonably congruent with STR observations and therefore sufficiently probative as basis for the panel’s recommendation with regard to §4.71a ROM criteria. Those measurements satisfied 10% criteria for extension (code 5251) and for adduction and external rotation (code 5253). Additionally there was satisfactory evidence of painful motion to support a minimum 10% rating. It was noted that the VA rating of 20%, based on the 12-month C&P examination, cited the 5253 criterion for abduction (motion lost beyond 10 degrees), but members agreed that this was overly speculative since it was not corroborated by the C&P examiner. There was no ankylosis (5250) or flail joint (5354) that would support a higher rating under the remaining §4.71a joint codes. The panel considered whether the disability in evidence merited analogous rating under code 5299-5255 (femur, impairment of). Member consensus was, however, that the analogous application of this fracture code (complications of non-union or malunion) was not sufficiently justified since this case satisfies compensable criteria under more applicable joint codes. After due deliberation, considering all the evidence and with deference to reasonable doubt, the panel’s consensus recommendation is a 10% rating for the right hip/SIJ condition under code 5099-5024 (analogous to tenosynovitis).

Contended PEB Conditions: Diabetes Mellitus, Hypercholesterolemia, Hypertension, Exogenous Obesity, Restrictive Lung Disease, Seborrheic Dermatitis, Psoriasis, Gastroesophageal Reflux Disease (GERD), Urinary Incontinence, Right Ovarian Cyst, Thoracic Outlet Syndrome (TOS), Cervical Spine Spondylosis, Degenerative Joint Disease (DJD), and Migraine Headaches. The CI was diagnosed with uncomplicated early diabetes that was controlled on oral medication; with high-risk hypercholesterolemia that was responding to medication at separation; and, with stable hypertension. The obesity was baseline and familial, but compounded by the orthopedic conditions as above; and, regardless, is not subject to disability rating. The restrictive lung disease was mild (not meeting minimum 10% PFT criteria for VASRD rating) and attributable to the worsening obesity. The skin conditions were mild and cleared for retention by a dermatology addendum. The GERD remained symptomatic at separation (compounded by obesity), but was reasonably controlled on medication.  A general diagnosis of DJD was attributed to obesity  and

encompassed the orthopedic conditions already addressed, and to knee pain which is not in the panel’s scope of review as defined above.

Some "mild urinary urge incontinence” after the bladder suspension surgery was cleared for full duty by a urology addendum. The CI underwent surgery for a right ovarian cyst and adhesions in 2002, and periodically suffered some unexplained right lower abdominal pain after that. No etiology was identified by an extensive work-up, and no active symptoms were documented in the pre-separation general C&P examination or final NARSUM addendum. Diagnoses of possible TOS and mild cervical degenerative disc disease were made during the course of orthopedic evaluation of right upper extremity pain. Electrodiagnostic testing was normal and the only consistent symptom at separation was intermittent hand numbness without weakness. Functional impairment was characterized as “minimal” in the pre-separation VA joint C&P (incongruent with VA rating of 20% under a nerve code), and no associated symptoms were referenced in the final orthopedic or NARSUM addendums.

The CI had a 10-year history of migraine headaches that were intermittently treated in service.  A neurology addendum to the NARSUM opined that the condition did “not meet military requirements,” although a VA neurology C&P examination from the same period stated that she continued working when the headaches occurred. A NARSUM revision contemporary with the neurology addendum characterized the headache condition as chronic and stable, and it was not noted at all in the final NARSUM addendum.

The only LIMDU boards in evidence were for coagulopathy during active treatment and for the lumbar spine condition. As noted above, the initial PEB accounted for all conditions and found the CI fit for duty. Only the lumbar spine and right hip/SIJ pain were contested. The commander’s NMA was not probative to separate fitness implications of the multiple conditions, but noted that the CI averaged two hours a week of work loss for medical appointments (not for incapacitating symptoms), and stated that her performance remained “outstanding” with administrative assignments.

The panel’s main charge is to assess the fairness of the PEB determinations that the contended conditions were not unfitting. It would be reasonable to assume that there was some combined effect overlap of these multiple conditions with the unfitting conditions, but members agreed that there was insufficient performance-based evidence that any of them (either alone or in combination) interfered with satisfactory duty performance at separation to an extent that would have precluded continued military duty. This included due consideration of the MEB neurology opinion regarding the migraine headaches, but it was agreed that there was a preponderance of contrary evidence. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB Category III adjudications for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the lumbar spine condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the asthma, the panel recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97. In the matter of the contended right hip pain (subsuming sacroiliac joint pain), the panel majority recommends it as a separately unfitting condition rated 10%, coded 5099-5024 IAW VASRD §4.71a. The single voter for dissent recommends no change from the PEB Category III adjudication and does not elect to submit a minority opinion. In the matter of the contended venous thromboembolic disease, deep vein thrombosis, hematoma formation, diabetes mellitus, seborrheic dermatitis, psoriasis, gastroesophageal reflux disease, urge urinary incontinence, thoracic outlet syndrome, exogenous obesity, migraine headaches, right ovarian cyst, restrictive lung disease, degenerative joint disease, hypercholesterolemia, cervical spine spondylosis, and hypertension, the panel

recommends no change from the PEB Category III adjudications. There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Lumbar Spine/Sacroiliac Degenerative Disc Disease	5237	10%	
Asthma	6602	30%	
Right Hip/ Sacroiliac Joint Pain of Unclear Etiology	5099-5024	10%	
	COMBINED	40%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170119, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD DC 20374-5023

IN REPLY REFER TO

1850
CORB:003
2 Jun 20

From: Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:   (a) DoDI 6040.44
(b) PDBR ltr of 25 Apr 19

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

2.	On 27 May 2020, the Assistant Secretary of the Navy took action in your case by accepting the correct recommendation of the PDBR. Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Physical Evaluation Board from 20 to 40 percent with assignment to the Permanent Disability Retired List.

3.	The Assistant Secretary’s determination, which represents final action in your case by the Department of the Navy, was sent to the Navy Personnel Command, for correction of your records as stated above. You will be notified once those changes are complete.

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