RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXX	CASE: PD-2017-03149
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20061013

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Engineman, medically separated for “lumbago” with a disability rating of 10%.

CI CONTENTION: “Surgery was required to fix my L5 vertebrae and the nerve damage in my lower back that was not discovered or taken into account, nor was the damage to my feet due to service connected spinal injury.”  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 - 20060718	VARD - 20070608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbago	5299-5237	10%	Arthritic Spondylosis of Lumbar Spine with Lumbago	
5242	
20%	
20070320	
Bilateral Pars Defects	Cat II					
Spondylolysis	Cat II					
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Lumbago. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in 2005 without specific injury or trauma. At an examination in December 2005, the CI had tenderness along the latissimus dorsi and trapezoid muscles bilaterally from T4 to T9 with some radiation down the right flank and buttock area. There was very mild rotoscoliosis (curvature of the spine) at about the T7 level, but his gait was

normal. X-rays showed bilateral abnormal appearance of the pars interarticularis of L5, and a CT scan showed L5 spondylolysis (defect or fracture in the pars interarticularis) and minimal disc bulge at L5-S1 without significant spinal canal stenosis. There was STR evidence of normal gait, range of motion (ROM) and lower extremity strength; however, several examinations showed tenderness and painful motion. A March 2006 MRI demonstrated bilateral narrowing of the lateral recesses at L4-5 level by hypertrophic osteophytes from the articular facets with no nerve impingement appreciated.  The CI was not a surgical candidate.

The 5 June 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of significant and debilitating lower back pain. Physical examination revealed an antalgic gait with significant diffuse tenderness over the L4-S1 paravertebral musculature bilaterally and normal motor strength. He was able to do five toe raises slowly of the bilateral lower extremities. Straight leg raise testing was negative. No ROM measurements were listed. Operative and non- operative interventions were discussed and pars injections were offered, but the CI did not wish to proceed.

At the 20 March 2007 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported low back pain with stiffness, occasional swelling and intermittent numbness. He ambulated with an antalgic gait favoring the right lower extremity. Physical examination showed a moderate loss of normal lordosis and bilateral paraspinal tenderness. Thoracolumbar ROM measurements recorded active flexion to 40 degrees (normal 90) and combined ROM of 185 degrees (normal 240), all with pain after repetitive motion.

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 Navy PEB listed “bilateral pars defects” and “spondylolysis” as related Category II diagnoses (contributing to the disability). The panel concluded the Category II diagnoses were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without pyramiding (VASRD §4.14). The VA rated the back condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing lumbago (pain) in the lumbar spine, X-ray evidence of spondylosis (arthritis) and forward flexion of 40 degrees.

While the PEB rated the back condition on painful motion and tenderness, there were no quantitative ROM measurements recorded on which to provide a rating. However, prior to separation, full ROM with pain was noted on at least two STR examinations, but there was no evidence in the case file of an intervening traumatic event that would account for the decrement of the ROM for flexion to 40 degrees, as recorded on the VASRD-compliant post-separation VA examination. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority 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 majority recommends no change in the PEB adjudication. The single voter for dissent recommended modification to 20% but did not elect to submit a minority opinion. 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

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 7 May 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 of no 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.