RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXX	CASE: PD-2017-02279
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20070502

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Builder, medically separated for “low back pain” with a disability rating of 20%.

CI CONTENTION: In addition to the 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 - 20070502	VARD - 20070714	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5242	20%	Lumbar Spine Degenerative Disk Disease With Herniated Disc L4-5 without Evidence of radiculopathy	
5242	
20%	
2070714	
L4-L5 Neuroforaminal Stenosis	
Cat II					
Bulging Disc L4-L5						
L4-L5 Disk Protrusion						
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Low Back Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in late 1998 after heavy lifting, and was exacerbated in May 2005 after holding a heavy load. During the 17 October 2006 MEB NARSUM examination, 7 months prior to separation, the CI reported persistent back pain which limited performance of duties.   Physical examination revealed curvature of the lower spine somewhat flattened    from

normal. Range of motion (ROM) was reported as flexion with hands to his knees, with “extension and side bending normal.”

The 8 November 2006 physical medicine MEB addendum, 6 months prior to separation, noted complaints of back pain rated 3-4/10 in severity with two or three bad days per week when the pain flared to 6/10. Physical examination showed a normal gait and posture with a normal appearing spine. Neurologic examination was normal. Thoracolumbar ROM testing (after 3 repetitions) showed flexion of 35 degrees (normal 90) and combined ROM of 185 degrees (normal 240), limited by pain.

During the 11 December 2006 orthopedic consultation, 5 months prior to separation, the CI reported moderate back pain rated 3/10 in severity, unchanged in severity over the course of the previous 18 months. Physical examination showed tenderness of the lower back with no spasm. Neurologic examination was normal, and ROM was recorded as flexion to 45 degrees and combined ROM of 195 degrees.

At the 2 July 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant back pain with morning stiffness and periodic flares of increased pain which limited standing to 15 minutes and walking to one mile. Physical examination showed normal gait and posture, but slight flattening of lower spine curvature, with tenderness present but no spasm. After 3 repetitions, thoracolumbar ROM was recorded as flexion to 60 degrees and combined ROM of 190 degrees with painful motion observed.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition at 20%, coded 5242 (degenerative arthritis of the spine). The PEB also listed L4-L5 neuroforaminal stenosis, bulging disc L4-5, and L4-L5 disk protrusion as related diagnoses contributing to the disability in this case. The panel concluded these Category II diagnoses were intrinsic to the rated back condition and separate ratings cannot be supported without pyramiding (VASRD §4.14). These Category II conditions are therefore properly subsumed under the rating for the back condition. The VA also rated the back condition 20%, coded 5242, based on the C&P examination citing pain on motion and decreased ROM after repetitive motion.

The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees), as reported on all examinations proximate to separation. 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 back condition.

BOARD FINDINGS: In the matter of the back condition 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 20170303, 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 20May20

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 <ltd 29 Mar 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.

Copy to: PDBR