RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2018-00411
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20080404

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Special Security Assistant, medically separated for the overall effect of “upper back and cervical pain,” ”epigastric pain, gastritis,” and “anxiety disorder, NOS [not otherwise specified],” with a combined disability rating of 0%.

CI CONTENTION: “VA rating decision dated December 14, 2017 reflects a combined rating of 90%.” 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 - 20080229	VARD - 20080821	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Upper Back and Cervical Pain			Back Injury	5299-
5237	NSC	STR	
Epigastric Pain, Gastritis	OE	0%	Gastrointestinal Condition claimed as Gastritis; Gastric Disorder; Abdominal Pain	7399-
7307	NSC	STR	
Anxiety Disorder, NOS							
			Anxiety	9499-
9400	NSC	STR	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:

Upper Back and Cervical Pain, Epigastric Pain, Gastritis and Anxiety Disorder, NOS. The PEB determined that the CI was unfit due to the “overall effect” (OE) of multiple conditions. In an OE case, each condition has been determined by the PEB to be separately not unfit, but the OE considered together creates a condition of unfitness. In these cases, the panel evaluates each condition separately for fitness and does not recommend a rating unless a preponderance of evidence demonstrates that a specific condition was separately unfitting at separation. Each condition is summarized below with discussion of individual fitness and rating if indicated.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s upper back and cervical condition began in June 2006 after falling down a flight of stairs. Between June 2006 and June 2007 the CI reported mid to upper thoracic back pain that did not radiate. At serial examinations in the STR tenderness of the thoracic musculature was noted with normal or mild limitation of motion of the thoracic spine. Cervical spine examination was normal. Thoracic X-rays and cervical and thoracic MRI in November 2006 were normal. The CI did not benefit from physical therapy (PT) and declined a consultation with pain management. She was unable to tolerate non-steroidal anti-inflammatory (NSAIDs) medications due to gastrointestinal (GI) side effects and an opiate pain medication (Darvocet) was helpful in managing pain, but did not resolve her back pain.

The CI developed epigastric pain and GI bleeding following use of NSAIDS for her back pain. She refused evaluation of the bleeding due to family history of complications and also due to her religious beliefs, which precluded a blood transfusion. Occult blood testing (blood in stool) was positive in December 2006. Complete blood counts in November and December 2006 and January and December 2007 were normal, without evidence of anemia. The CI was treated with an acid-reducing medication for peptic ulcer disease and her episodes of bleeding and GI symptoms decreased. In the months leading up to the MEB NARSUM she denied any evidence of GI bleeding (blood in stool or vomiting of blood). At a primary care examination on 10 December 2007, the CI reported vomiting up a small amount of blood, as she had done in the past. Physical examination showed mild tenderness in the upper abdomen (epigastrium), without enlarged organs or evidence of a surgical emergency (no rebound tenderness). The assessment was gastritis and use of Celebrex (an NSAID) was discontinued.

In the matter of the anxiety disorder, there were no STR visits in the available record that indicated the CI reported any mental health (MH) symptoms prior to the MEB NARSUM. At the MEB NARSUM the CI reported no MH symptoms and no MH condition was listed as a diagnosis. The NARSUM examiner noted that the CI had recently been started on Pamelor, an antidepressant medication, also used to treat chronic pain.

Regarding the upper back and cervical pain, the 4 June 2007 MEB NARSUM, 10 months prior to separation, listed diagnoses of “upper back and cervical pain” and “epigastric pain, gastritis.” The MEB NARSUM examiner referred to the back condition noting the CI would require ongoing medication treatment, PT, and home PT, and after a 12-month trial of conservative treatment for her non-surgical back pain, the CI was unable to return to full duty. Physical limitations were no running, no lifting more than 25 pounds, no deployment or shipboard duty, no individual augmentation, no prolonged standing more than 10 minutes.

The 30 June 2007 abbreviated MEB Report, also known as a limited duty evaluation or LIMDU, listed mid-back pain and gastritis with physical limitations as noted on the MEB NARSUM above. The 20 August 2007 non-medical assessment (NMA), 8 months prior to separation, indicated that the CI’s physical limitations did not affect her ability to perform her daily functions, which were primarily clerical in nature and very little of what she did every day required strenuous activity, but the CI was not able to take a physical readiness test or physical fitness assessment. The NMA stated the CI expressed to her chain of command the desire to separate from the Navy at the earliest possible opportunity. The MEB NARSUM listed diagnoses of “upper back and cervical pain” and “epigastric pain, gastritis.” The MEB forwarded backache, unspecified and “unspecified gastritis and gastroduodenitis, [without] hemorrhage.”

The 13 September 2007 Informal PEB found the CI fit for duty. The CI appealed to the Formal PEB (FPEB) and presented additional medical information from primary care visits in 2008 and an emergency room visit in January 2008, which is not in record. The CI requested to be found unfit for upper back and cervical pain, rated 0% and anxiety disorder, NOS, rated 0%.

At a primary care examination on 15 January 2008, 3 months prior to separation, the CI reported concerns about anxiety with persistent worry. She denied chest pain, rapid heartbeat, dizziness or tingling of the hands or feet. She reported anxiety interfered with her work. She denied irritability, hostility, sleep problems, or abnormal thoughts. Mental status examination showed a flat affect and the examination was otherwise normal. Counseling was advised, but the CI declined. A low dose of anti-anxiety medication was prescribed for acute episodes. At a primary care visit one week later (24 January), the CI reported an emergency room visit for lightheadedness, and that she developed this when she was anxious at her job. She declined a MH evaluation.

A 21 March 2008 primary care examination, one month prior to separation, the examiner indicated the CI needed to see a GI specialist for evidence of GI bleeding. The CI was advised to stop use of Mobic, an NSAID. Physical examination showed full range of motion (ROM) of the back with tenderness of the thoracic spine and trapezius muscles.

The FPEB found the CI unfit based on OE of “upper back and cervical pain,” “epigastric pain, gastritis,” and anxiety disorder, NOS, rated 0%. The FPEB noted the CI’s 2-year history of neck and upper back pain diagnosed as trapezius muscle strain; her history of NSAID use and gastritis; and, recent diagnosis by primary care of anxiety, with prescription of anti-anxiety medication (Xanax). The CI reported she resisted further MH evaluation due to concerns about her security clearance. The FPEB noted that due to recent Rate changes, the CI’s duties now included moving heavy packages and she reported she needed assistance to move the boxes. She also reported loss of 10 to 20 minutes throughout the day for medical management of her anxiety symptoms.

The panel first considered if any OE condition was unfitting when considered individually. The LIMDU forms listed mid-back condition, was implicated in the NMA and failed retention standards. The “epigastric pain, gastritis” was noted on LIMDU forms, but was not implicated in the NMA and did not fail retention standards. The anxiety disorder, NOS was not listed on LIMDU forms or implicated in the NMA, and did not fail retention standards. There was no performance- based evidence that the “epigastric pain, gastritis” or anxiety disorder, NOS significantly interfered with satisfactory duty performance at separation, however, physical limitations related to the back impaired the CI’s successful performance of her duties. Based on the evidence the panel concluded there was a preponderance of evidence that the upper back and cervical pain condition was unfitting, but there was not a preponderance of evidence that the “epigastric pain, gastritis” or anxiety, NOS were unfitting for continued military service.

The panel next considered if each of the upper back and cervical pain remained separately unfitting when removed from the PEB’s combined adjudication. As noted above in overall effect cases the must be a preponderance of evidence that a condition was unfitting for the panel to recommend a rating. The mid-back was noted on the LIMDU, but not neck pain. The NMA noted the CI’s physical limitations impaired her duty performance without identifying her medical conditions. At the MEB NARSUM the CI reported neck and upper back pain, however, throughout the STR the CI reported mid- and upper back pain, with no mention of neck pain. Imaging of the cervical and thoracic spine was unremarkable. Cervical spine examinations in the STR were normal and the only examination to note tenderness of the neck was the NARSUM. Whereas, all examinations in the STR noted thoracic tenderness and/or painful motion. The panel concluded there was a preponderance of evidence that the upper back condition was unfitting but not the cervical condition. Accordingly, the panel considered a single rating recommendation for the upper back condition.

On physical examinations in the STR, tenderness of the thoracic spine muscles (trapezius, rhomboids) were consistently noted but the cervical spine was normal, with full painless ROM and no tenderness or muscle spasm noted. Thoracic spine ROM was reported as full or mildly

decreased with painful motion, mainly with extension of the thoracolumbar spine. Cervical and thoracic spine MRI and thoracic X-rays were all normal.

At the MEB NARSUM physical examination, 10 months prior to separation, physical examination showed the neck was supple and had full ROM. There was full ROM of the back with flexion/extension and lateral flexion bilaterally. The CI was tender to palpation of the paraspinal muscles bilaterally from the level of the lower scapula up to the base of the skull. No muscle spasms were noted. As noted above, a primary care examination in January 2008, one month prior to separation, documented full ROM of the back with tenderness of the thoracic spine and did not address the neck.

The panel directed attention to its rating recommendation for the upper back condition based on the above evidence. The PEB rated the upper back condition with the other conditions 0%, based on overall effect. The VA did not service connect “back injury” because the CI failed to attend a VA examination, therefore there was no VA examination proximate to separation in evidence.

Although there was insufficient limitation of motion to support a 10% rating, the panel agreed a 10% rating was justified for the presence of thoracic spine tenderness as noted at the MEB NARSUM examination. There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis. There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the upper back condition, coded 5237 (lumbosacral strain).

BOARD FINDINGS: In the matter of the overall effect of “upper back and cervical pain, epigastric pain, gastritis and anxiety disorder, not otherwise specified, the panel recommends a disability rating as follows: an unfitting upper back condition, rated 10%, coded 5237 IAW VASRD §4.71a; and not unfitting cervical pain; “epigastric pain, gastritis”; and, unfitting anxiety disorder, not otherwise specified . 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	
Upper Back Pain	5237	10%	

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 12 Oct 20

From: To:

Subj:

Ref:

Director, Secretary of the Navy Council of Review Boards 
PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
(a) DoDI 6040.44
(b)	PDBR ltr of 8 May 20
(b)	

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy for appropriate action.

2.	On 7 October 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) took action in your case by accepting the recommendation of the PDBR. Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Department of the Navy Physical Evaluation Board (PEB) from 10% to 20% without re-characterization of your discharge.

3.	For your information, since all disability ratings from 0% to 20% qualify for disability severance pay, the above stated increase will not result in your entitlement to additional compensation.

4.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, has been forwarded to the Navy Personnel Command for appropriate changes to your personnel records and notification to you upon completion.