RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-03406 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20090813

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Personnel Specialist, medically separated for “low back pain (LBP) with radiculopathy” with a disability rating of 10%.

CI CONTENTION: Review of all conditions requested. 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 – 20090415	VARD - 20090924	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LBP with Radiculopathy	5237	10%	Lumbar Spine Degenerative Disc Disease	5242	20%	20090924	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

LBP with Radiculopathy. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition started in 2004, when she was leaning over and felt immediate LBP and radiation to her left lower extremity (LLE). Lumbar spine X-rays were unremarkable and she was treated with physical therapy. In 2007, her symptoms became more persistent. She was seen by a civilian spine surgeon whose workup included an MRI which revealed small disc bulges at L4-5 and L5-S1, compromising the left L4 foramen and contacting the left S1 nerve root. She was treated by a pain medicine specialist with epidural steroid injection and non-operative modalities with improvement in her symptoms. At a follow-up examination on 12 January 2009, the CI reported continued LBP that occasionally radiated down the LLE. A CT myelogram performed on 15 January 2009 indicated clearance of the herniated disk and showed no significant abnormalities from T12 to S1. The CI was treated with an anti-inflammatory medication (Mobic) which was helpful. However, she subsequently reported right-sided symptoms and continued to receive treatment.

The 16 March 2009 MEB NARSUM examination, 5 months prior to separation, noted complaints of LBP with radiation to the bilateral LEs. Physical examination revealed range of motion (ROM)

was flexion of 80 degrees (normal 90); lumbar extension was 30 degrees (normal); and lateral pivot was 0-40 degrees bilaterally (normal 30). Straight leg raise testing to elicit radicular symptoms was negative bilaterally. There was no tenderness along the spine. Motor strength and deep tendon reflexes were normal and sensation was intact from L3 to S1 dermatomes, except for decreased sensation over the L4 dermatome on the right side. The back pain and radiation to her bilateral legs was worsened by driving and heavy activity. She was unable to adequately jog and perform strenuous duty without pain.

At the 7 August 2009 VA Compensation and Pension (C&P) examination, one week before separation, the CI reported constant LBP that intermittently radiated down to the toes, with paresthesias. She reported stiffness, muscle spasm and bilateral generalized LE weakness. The CI reported she could walk for up to 30 minutes before her back limited her and she wore a back support when mowing the lawn or performing other strenuous activities. The CI denied significant flare-ups or incapacitating episodes in the past 12 months. Physical examination revealed a normal gait. The lumbar spine was not tender. Back ROM was flexion to 60 degrees limited more by stiffness than pain, and combined ROM of 185 degrees (normal 240) with noted pain and stiffness and increased pain with repetitive flexion, but no additional loss of motion. LE strength, sensation, and reflexes were normal. X-rays revealed mild to moderate degenerative changes.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 10%, analogously coded 5237 (lumbosacral strain). The VA rated the low back condition 20%, analogously coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined ROM of the thoracolumbar spine not greater than 120 degrees.

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) and/or combined ROM not greater than 120 degrees), as reported on the VA examination, the most proximate examination to separation. There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition. Proximate to separation the CI reported radiation of pain to the LEs, however, imaging and clinical testing to elicit radicular symptoms were negative and on examination LE strength, sensation and reflexes were normal. Radiating pain from the back is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” There was no evidence in this case that weakness or sensory deficit of either the LEs existed to any degree that could be described as functionally impairing. The panel therefore concluded that separate disability ratings were justified on this basis. After due deliberation, considering all the evidence and mindful of VASRD
§4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the back condition, coded 5237.

BOARD FINDINGS: In the matter of the low back condition, the panel recommends a disability rating of 20%, 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, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain with Radiculopathy	5237	20%	

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
6040
CORB:003 14 May 21

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

Subj:	Physical Disability Board of Review Determination Ref:	(a) 6040.44(Series)
1.	The Physical Disability Board of Review (PBDR) reviewed your case in accordance with reference
(a) and forwarded their recommendation for action.

2.	On 23 April 2021 the Assistant Secretary of the Navy (Manpower and Reserve Affairs) accepted the PDBR’s recommendation of an increase in disability rating to 20%. This decision was then sent to Navy Personnel Command for appropriate action.

3.	The PDBR determination is final and not subject to appeal or review.