RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:XXXXXXXXXXXXXXXXXX	CASE:  PD-2017	-0418	0
BRANCH OF SERVICE:  NAVY	SEPARATION DATE: 20080627

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Master-at-Arms, medically separated for “[lumbar] facet syndrome” with a disability rating of 20%.

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 – 20080305	VARD - 20081121	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Facet Syndrome	5242	20%	Lumbar Facet Arthropathy	5299-5239	20%	20080915	
Gastroesophageal Reflux	Cat III	Esophagitis Chronic Reflux	7399-7346	10%	20080915	
Onychomycosis	Cat III	Dermatophytosis Onchomycosis	7806-7813	0%	20080915	
Hypertension	Cat III	Essential Hypertension Benign	7101	0%	20080915	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Lumbar Facet Syndrome. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began insidiously in early 2004 and worsened later that same year after being in a motor vehicle accident. An MRI in June 2006 revealed a small disc bulge at L4-5 causing narrowing of the nerve-exiting canal, but electrodiagnostic testing performed in March 2007 was normal. A follow-up MRI in May 2007 showed no significant bony or soft tissue pathology, and the CI was not a surgical candidate.

During the 26 October 2007 MEB NARSUM examination, 8 months prior to separation, he complained of “…constant lower back pressure and discomfort,” and additionally endorsed extension of pain into the left lower extremity. The physical examination (PE) was neurologically focused and revealed decreased sensation in the distal aspects of the left leg and foot, but a mechanically symmetric gait. The 14 December 2007 range of motion (ROM) evaluation by pain

management, 6 months before separation, noted spinal flexion to 75 degrees (normal 90). A combined ROM could not be determined because rotary spine motions were not in evidence.

At the 15 September 2008 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI complained of frequent muscle spasms. The PE revealed no evidence of abnormal spinal contour or surrounding tenderness, and the ROM study showed flexion of 70 degrees and combined ROM of 175 degrees (normal 240), with pain in all directional movements.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 20%, coded 5242 (degenerative arthritis of the spine). The VA also rated the back condition 20%, analogously coded 5299-5239 (spondylolisthesis or segmental instability), based on the C&P examination, citing thoracolumbar forward flexion greater than 30 degrees but not greater than 60 degrees. Panel members agreed the ROM evidence proximate to separation warranted no greater than a 10% rating. However, IAW DoDI 6040.44, the panel may not recommend a rating lower than that awarded 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’s adjudication for the back condition.

Contended PEB Conditions: Gastroesophageal Reflux, Onychomycosis and Hypertension. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. None of the conditions were noted on limited duty forms, implicated in the non-medical assessment or determined by the MEB to fail retention standards. There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at or near separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB’s fitness determination for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended gastroesophageal reflux, onychomycosis and hypertension, the panel recommends no change from the PEB determinations as not unfitting. 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:

2	PD-2017-04180

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

IN REPLY REFER TO:

1850
CORB: 003
10 Sep 20

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.