RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX		CASE: PD-2017-03381 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20080114

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Advance Construction Mechanic, medically separated for “low back pain (LBP)” with a disability rating of 20%.

CI CONTENTION:  He continues to have pain.  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 - 20071015	VARD - 20081014	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LBP	5237	20%	Herniated Disc L5-S1, S/P Microdiscectomy	
5242	
10%	
20080707	
Herniated Nucleus Pulposis L5-S1	Cat II					
Status Post (S/P) Discectomy L5-S1	Cat II					
Left Knee Pain	Cat lll	Arthritis, Left Knee, Meniscal Tear	5260	10%	20080707	
Status Post Left Knee Arthroscopy	Cat III					
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 30%	
	
ANALYSIS SUMMARY:

LBP. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s low back condition began in September 2005 when he suffered a severe onset of LBP while attempting to stand from a sitting position. A 2 May 2006 MRI revealed L5-S1 disc herniation with right anterior thecal sac compression. In May 2006, the CI underwent an L5-S1 discectomy.

At the 7 February 2007 orthopedic evaluation, 11 months prior to separation, the CI reported continued LBP with radiation to the right thigh. He denied numbness, tingling, and bowel and bladder dysfunction. Physical examination showed thoracolumbar flexion of hands to mid-tibia full extension, with decreased rotation and lateral bending to the right. During the 15 October 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, physical examination revealed lumbar tenderness.

At the 7 July 2008 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported constant 6/10 LBP. The pain increased with physical activity. Physical examination showed no evidence of radiating pain on movement, muscle spasms, or tenderness. Thoracolumbar range of motion (ROM) was flexion to 90 degrees (normal) and combined ROM was 240 degrees (normal).  There was pain with flexion and left lateral flexion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 20%, coded 5237 (lumbosacral strain). The PEB also listed “herniated nucleus pulposus L5-S1” and “status post discectomy L5-S1”as a related Category II condition that contributed to the primary unfitting condition but was not separately ratable. The impairment from the herniated nucleus pulposus and “status post discectomy” were properly subsumed under the overall rating for the LBP Category I condition IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited). The VA rated the herniated disc L5-S1, s/p microdiscectomy condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. The panel concluded there was no limitation of motion or favorable ankylosis to support a rating higher than that adjudicated by the PEB. 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 lower back condition.

Contended PEB Condition: Left Knee Pain and S/P Left Knee Arthroscopy. The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. The contended condition was not noted on limited duty forms or implicated in the non- medical assessment and did not fail retention standards. There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the lower back condition IAW VASRD §4.71, the panel recommends no change in the PEB adjudication. In the matter of the contended left knee pain and s/p left knee arthroscopy condition, the panel agrees it cannot recommend it for additional disability rating. 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 dtd 3 Jul 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.

Copy to: PDBR