RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-00914
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20050921

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Aviation Ordnanceman, medically separated for “chronic low back pain [LBP] secondary to degenerative disc disease [DDD]” with a disability rating of 10%.

CI CONTENTION: “Muscle spasms, limited mobility, guarded walk.” 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 - 20050608	VARD - 20061003	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP Secondary to DDD	5242	10%	Chronic LBP with DDD and Herniated Disc	5010-5242	10%	20060915	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Chronic LBP secondary to DDD. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s LBP began in 1999 from heavy lifting and was reinjured in 2002 after being hit by a catapult on deck. He was treated with physical therapy, anti- inflammatory medications, and chiropractic treatments. In early spring 2004, his symptoms progressed to the point where he sought additional medical treatment. The 25 May 2004 MRI showed degenerative disc changes at the lower lumbar levels, as well as a disc extrusion at the L5-S1 level. He was then referred for orthopedic evaluation and received additional treatment including lumbar epidural steroid injections. In May 2004, he was unable to perform his military

duties, placed on limited duty, and submitted to the PEB for further evaluation, disposition, and adjudication.

The 21 March 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of intermittent to frequent dull aching LBP, described as slight to moderate in intensity, with occasional sharp and shooting pain. His symptoms worsened with bending, stooping, lifting, pushing, and pulling. Physical examination of the lumbar spine showed no obvious deformities. There was mild tenderness at the lumbosacral spine region but no obvious spasm of the paraspinous muscles of the lumbar spine. Range of motion (ROM) showed flexion of 70 degrees (normal 90) and combined ROM of 200 degrees (normal 240).  Painful ROM was not addressed.

At the 15 September 2006 VA Compensation and Pension (C&P) examination, 11 months after separation, the CI reported chronic LBP progressively worsening. Physical examination showed normal gait and spinal contour. There was no spasm, atrophy, guiding, painful motion, tenderness, or weakness. There were signs of lumbar flattening. Flexion of 70 degrees and combined ROM was 220 degrees with no additional loss of function after repetitive ROM.

The panel directed attention to its rating recommendation based on the above evidence. The PEB and VA both rated the LBP 10%. The PEB used code 5242 (degenerative arthritis of the spine) while the VA dual coded 5010-5242, based on the STR and C&P examinations, citing forward flexion of 70 degrees. The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB NARSUM and VA examinations. There was no muscle spasm or guarding to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis. There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula. 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 LBP.

BOARD FINDINGS: In the matter of the chronic low 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.

2	PD-2017-00914

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

IN   REPLY  REFER  TO,
1850
CORB: 003 20May20

From: To:

Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW  (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 21 Apr 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate  action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR ofno 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.