RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02027
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070311

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Laundry and Repair Specialist, medically separated for “endometriosis” with a disability rating of 10%.  “Low back pain” was determined to have existed prior to service (EPTS) and was not rated.  

CI CONTENTION:  In addition to the endometriosis and back condition, the CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20070109	VARD - 20080327	
Condition	Code	Rating	Condition	Code	Rating	Exam	
History of Endometriosis	7699-7629	10%	Abdominal Hysterectomy 	7618	30%	STR	
Chronic Low Back Pain	5237	EPTS	Lumbosacral Strain	5237	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Endometriosis.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent diagnostic laparoscopy surgery on 15 April 2005 which showed endometriosis on the anterior abdominal wall, right round ligament and posterior cul-de-sac.  Endometriosis in the vascular spaces could not be ablated.  She subsequently underwent a total hysterectomy on 12 August 2005.  In February 2006, she underwent another diagnostic laparoscopy, which was otherwise normal, and the granulation tissue was removed from the vaginal cuff.  

During the 19 May 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 10 months prior to separation, the CI reported lower abdominal pain.  Physical examination revealed mild suprapubic tenderness and a suprapubic horizontal scar.  On 29 June 2006, an ultrasound study ordered for persistent pelvic pain, was normal.  

The 13 July 2006 MEB NARSUM addendum, 8 months prior to separation, noted complaints of pelvic pain.  Physical examination showed a flat, soft abdomen with normal bowel sounds.  The CI had diffuse direct tenderness of the abdomen without rebound and no masses were palpated.  However, she continued to have pain postoperatively and retreated with depo Lupron (a hormone suppressor) and oral contraceptives without pain relief.  A CT scan was reported to show a 3 cm left ovarian cyst.  On examination there was direct tenderness in the left lower quadrant of the abdomen, which was soft and without rebound tenderness or palpable masses.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the endometriosis 10%, analogously coded 7699-7629 (endometriosis), citing chronic pelvic pain.  The VA rated the endometriosis 30%, coded 7618 (uterus, removal of, including corpus), based on the STR examinations, citing loss of the uterus following a period of postsurgical convalescence.  

The panel noted the CI had a history of chronic pelvic pain secondary to endometriosis, which persisted despite laparoscopic procedures, hysterectomy, depo Lupron and narcotic medications.  A 30% rating under code 7629 requires pelvic pain or heavy or irregular bleeding not controlled by treatment.  Therefore, a 30% rating is warranted and appropriate.  Use of code 7618 likewise offers a 30% rating option since the CI underwent a hysterectomy and had persistent pain after surgery that was not responsive to medications including depo Lupron and narcotic medication.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the endometriosis, coded 7699-7629.  

Chronic Low Back Pain.  According to the STR and MEB NARSUM, the CI’s low back condition began in November 1998 after a ruck march during basic training.  At a physical therapy evaluation on 3 January 2005 the CI had full range of motion (ROM) of the lumbar spine with pain at the end range of flexion and extension.  At a clinic visit on 30 March 2005 the CI complained of new low back pain, which began 5 days earlier after doing sit-ups.  She noted the quality of the pain was different from her back pain in the past.  On examination the back was tender.  

On 15 July 2005 the CI complained of thoracic back pain after carrying sand bags 2 days earlier.  On examination there was swelling and tenderness of the mid back in the left paraspinal region.  An MRI dated 2 November 2005 demonstrated small broad-based disc bulges and osteophyte complexes without significant spinal canal or neural foraminal stenosis at L4-5 and L5-S1.  A lumbosacral spine series dated 3 November 2005 was normal.  

A physical therapy evaluation showed active ROM of the lumbar spine was within normal limits with pain at the end of bending motions.  There was tenderness of the transverse processes at L4-L5 bilaterally.  On 24 February 2006 the CI reported worsening of her back pain.  At an orthopedic clinic visit, on 16 March 2006, examination revealed lumbosacral spine tenderness.  Straight leg raising (to determine nerve root irritation) was positive at 45 degrees.  There were no muscle spasms.  At both a pain management visit and orthopedic clinic visit in April 2006, the CI reported ongoing back pain for 7 years with a gradual increase in pain over the prior year.  At an orthopedic clinic examination on 24 April 2006, the CI reported lower back pain radiating to the left posterior thigh.  There were no muscle spasms or tenderness.  Thoracolumbar ROM was full and lumbosacral spine motion was normal.  

During the 19 May 2006 MEB examination (recorded on DD Forms 2807-1 and 2808) and MEB NARSUM examination, 10 months prior to separation, the CI reported progressively worsening back pain since November 1998, aggravated by activities such as lifting, bending and running long distances.  ROM testing showed forward flexion of 95 degrees (normal 90) and combined ROM of 190 degrees (normal 240) with pain.  Gait and thoracolumbar spine appearance were normal and there were no spasms, but there was tenderness.  During straight leg raise testing, the CI complained of pain in the lumbar spine area on both sides at about 85-90 degrees of elevation.  Lower extremity sensation, reflexes and strength were normal.  The commander’s statement dated 25 May 2006 implicated the back pain as contributing to the CI’s inability to perform duties.  

At an orthopedic clinic visit, on 10 August 2006, flexion was 95 degrees and combined ROM 190 degrees with pain.  There was tenderness of the spinous processes at L4-5 and the sacrum exhibited tenderness.  Straight leg testing was positive, but there were no radicular symptoms or muscle spasms.  Gait and stance were normal and neurologic examination was unremarkable.  A permanent L3 profile, for low back pain, was issued on 28 November 2006.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined the back condition, coded 5237 (lumbosacral strain) to have existed prior to service (EPTS) and was not rated, citing a gradual progression of a pre-existing condition and no evidence of permanent service aggravation.  The VA indicated the back condition was not service connected and did not rate it, stating the CI did not report for a VA examination and based on the evidence of record did not demonstrate a chronic condition subject to service connection.  

The panel noted the back condition first developed during a prior enlistment from 1998-2002 and the CI complained of a new form of back pain in March 2005.  Clear and unmistakable evidence is required to show that the condition was not service aggravated, and there is no evidence to support the notion that the condition was not service aggravated.  Thus, a rating is warranted.  The panel 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 on the examinations proximate to separation.  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 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 recommends a disability rating of 10% for the back condition, coded 5237.  

BOARD FINDINGS:  In the matter of the endometriosis, the panel recommends a disability rating of 30%, coded 7699-7629 IAW VASRD §4.116.  In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  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	
Endometriosis	7699-7629	30%	
Chronic Low Back Pain	5237	10%	
COMBINED	40%	

The following documentary evidence was considered:  

Exhibit A.  DD Form 294, dated 20170207, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20190005962, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, Ms. Stacey P. Clark, 76 South Laura Street, Jacksonville, FL 32202-3433.

Sincerely,					      
Enclosure