RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-03564
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20091213

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty, Cryptologic Technician, medically separated for “left sacroiliac (SI) joint dysfunction” with a disability rating of 10%.

CI CONTENTION: The CI submitted a lengthy contention for her unfitting back condition noting that the VA rated her condition 40%.  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 - 20090731	VARD - 20090930	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left SI Dysfunction	5236	10%	Left SI Joint Dysfunction (Formally diagnosed as Left SI Joint Dysfunction with Somatic Dysfunction of the Lumbar Spine and Left Piriformis)	
5299-5236	
0%	
20091027	
Somatic Dysfunction of the Lumbar Spine	Cat II					
Left Piriformis Syndrome	Cat II					
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Left SI Joint Dysfunction. According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was originally evaluated in May 2008 following a 2-year history of left-sided, low back pain (LBP). Her pain began after she fell down a ladder while stationed shipboard. An MRI on 30 May 2008 was normal. At the time of the orthopedic clinic appointment on 26 March 2009, 9 months prior to separation, the CI reported 5/10 left SI

pain that wrapped around the left hip and moved up the paraspinal muscles. Aggravating factors were prolonged sitting, standing and walking. The only alleviating factor was rest. MRI and X- rays were normal. Physical examination showed her gait was slow and controlled. Her thoracolumbar range of motion (ROM) was recorded as 20% forward flexion, 20% extension, 20% lateral flexion. Neurological testing was normal. There was tenderness and her motor strength test was normal at 5/5.   Pain- limited ROM was noted as pain with daily activities.

The 1 May 2009 MEB NARSUM examination, 6 months prior to separation, noted a history of LBP. The CI reported pain reduction from 8/10 to 5/10. Physical examination showed tenderness over the sacral sulcus on the left, a positive flexion, abduction and external rotation on her Faber’s test (for SI joint dysfunction). She had a negative straight leg raise (SLR), normal distal motor strength, and symmetric reflexes. The examiner referenced the most recent thoracolumbar ROM as 80 degrees forward flexion (normal 90), 15 degrees extension (normal ), 30 degrees left flexion (normal) and 45 degrees right flexion (normal 30).

At the 27 October 2009 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported constant, moderate, left, LBP. The pain radiated down the left leg and up to the shoulder. The CI reported stiffness, spasm, decreased motion, paresthesia and numbness. There was no fatigue or weakness of the spine or leg nor bladder dysfunction. The LBP was exacerbated by physical activity and alleviated by rest, Flexeril, physical therapy, and chiropractic treatments. Pain flare-up resulted in difficulty with walking, standing for prolonged times, and decreased limitation of motion with bending. There were no hospitalizations, surgeries, or incapacitations. Physical examination showed tenderness at the left SI joint. There was no evidence of radiating pain on movement, muscle spasm, guarding of movement, or weakness. SLR and Lasegue’s sign tests were negative bilaterally. There was no atrophy or ankylosis of the thoracolumbar spine. ROM was measured as 90 degrees flexion, 30 degrees extension, 30 degrees right/left lateral flexion and 30 degrees right/left rotation. There was no further limitation of ROM with repetition and no mention of pain during ROM measurements.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the SI condition 10%, coded 5236 (SI injury). The VA rated the SI condition 0%, analogously coded 5299-5236, based on the C&P examination 2 months before separation, citing the examination that did not show painful motion. The Navy PEB listed somatic dysfunction of the lumbar spine and left piriformis syndrome conditions as related diagnoses (Category II) contributing to the disability in this case. 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 violation of VASRD §4.14 (avoidance of pyramiding).

There was no limitation of thoracolumbar spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine, however the NARSUM and VA examinations noted the presence of some painful motion and localized tenderness. A 10% rating was therefore warranted. On examination, lower extremity strength, sensation, and reflexes were normal. Provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative. 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 SI condition.

BOARD FINDINGS: In the matter of the left sacroiliac 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.

 	 	

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.