RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:	CASE: PD-2017-03047
BRANCH OF SERVICE:  NAVY	SEPARATION DATE: 20051130

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve O1, Student Pilot, medically separated for “left L5-S1 herniated nucleus pulposus with left S1 radiculopathy” with a disability rating of 10%.

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 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 - 20050727	VARD - 20060828	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left L5-S1 Herniated Nucleus Pulposus with Left S1 Radiculopathy	5299-5237	10%	Lumbar Spine Degenerative Disc Disease	5242	10%	20060525	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Left L5-S1 Herniated Nucleus Pulposus with Left S1 Radiculopathy. According to the service treatment record and MEB narrative summary (NARSUM), the CI was treated for a low back condition in September 2004 after experiencing approximately 6 months of lumbar spine and leg pain. An MRI showed a disc herniation at L5-S1, compressing the S1 nerve root. In February 2005 orthopedics indicated there had been substantial improvement in the leg pain following an epidural steroid injection but the back pain was still significant. The CI declined surgery.

During the 1 April 2005 MEB NARSUM, 9 months prior to separation, the CI complained of back and left leg pain aggravated by prolonged sitting. Physical examination revealed a normal heel and toe gait. There was slightly decreased sensation along the posterior aspect of the thigh and bottom of the foot, the left ankle reflex was decreased compared to the right (1+) and lower extremity motor strength was slightly decreased (4/5) for left great toe extension, but was otherwise normal. Examination maneuvers to elicit radicular symptoms were mildly positive.

The 13 July 2005 MEB NARSUM addendum, 5 months prior to separation, noted complaints of increased back pain. Physical examination recorded tenderness. Thoracolumbar spine flexion was 30 degrees and combined ROM was 140 degrees (normal 240). Bilateral straight leg testing (SLR) for radiculopathy was negative. Motor strength, sensation and reflexes of the left lower extremity were normal.

During the 25 May 2006 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported low back pain, stiffness and weakness with left S1 radiculopathy. Physical examination showed normal gait and spinal curvature without muscle spasm or tenderness. There was no evidence of radiating pain on movement. Bilateral SLR testing was negative. Thoracolumbar spine flexion was 65 degrees and combined ROM was 195 degrees with pain. There was no additional limitation of motion following repetitive motion, but there was increased pain. At a VA primary care examination on 13 November 2006, 12 months after separation, the CI had no current complaints and reported a history of intermittent back pain that he treated with anti-inflammatory medication as needed.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain). The VA also rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing limitation of ROM. Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees or combined ROM greater than 120 degrees but not greater than 235 degrees, as supported by the totality of evidence proximate to separation. Although the CI’s ROM was decreased during an acute exacerbation, there was no compelling evidence that showed the CI’s forward flexion was permanently or frequently limited to 30 degrees or less as shown in the primary care and MEB NARSUM addendum examinations. 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. Although the CI had intervertebral disc symptoms, there was no documentation of incapacitating episodes which would provide 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. The panel noted the CI reported radiating pain to the left lower extremity and electrodiagnostic studies showed evidence of radiculopathy. However, the CI denied having radicular symptoms at the MEB NARSUM addendum examination and other examinations proximate to separation showed no evidence of functional impairment (such as weakness) in the left lower extremity. Panel members agreed there was no performance-based evidence from the record that left lower extremity radiculopathy significantly interfered with satisfactory duty performance at separation. The panel therefore concluded that additional disability rating was not justified on this basis.

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:

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

I>l RE ?L Y REl' ER TO:
1850
CORB: 003
10 Sep20

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

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) Ref:	(a) DoDI 6040.44
1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy on 13 Aug 2020 for appropriate action.

2.	On 27 August 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.