RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX		CASE: PD-2020-00050 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20071228

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Information Systems Administrator, medically separated for “low back pain (LBP)” with a disability rating of 0%.

CI CONTENTION: She requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB). 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 - 20071119	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LBP	5237	0%	

No VA Proximate to Separation in Evidence	
Dextroscoliosis	
Cat II		
Myofacia Piriformis Syndrome			
Lumbar…Disc Degeneration			
SI Joint Dysfuntion			
Migraines	Cat III		
Cervical…Disc Degeneration			
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:

LBP. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back pain began as early as 1999 after falling. Radiographic studies performed in February 2006 showed a congenital left-curving spine (dextroscoliosis) and degenerative changes to the lower spine, with a small bulge in the L4-L5 intervertebral disc that caused no nerve root impingement.

The 25 October 2007 MEB NARSUM examination, 2 months prior to separation, noted complaints of 8/10 burning LBP that radiated down the left leg. Physical examination showed tenderness of the lower spine, positive for sacroiliac (SI) joint dysfunction (FABER) and painful motion noted; the examiner recorded “positive standing flexion. At the 14 November 2007 physical therapy (PT) examination, physical examination showed range of motion (ROM) recorded as flexion to 90 degrees (normal) with combined ROM of 235 degrees (normal 240), with no mention of painful

motion, tenderness, or spasm. There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back pain at 0%, coded 5237 (lumbosacral strain). The PEB also listed dextroscoliosis, myofascial piriformis syndrome, lumbar intervertebral disc degeneration, and SI joint dysfunction as related Category II diagnoses 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).

The panel agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the PT 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 low back pain, coded 5242.

Contended PEB Conditions: Migraines and Cervical Intervertebral Disc Degeneration. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. Neither of these conditions were noted on limited duty forms, implicated in the commander’s non-medical assessment, and they did not fail retention standards. There was no performance-based evidence from the record that either of the conditions 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 either of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the low back pain, the panel recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a. In the matter of the contended migraines and cervical intervertebral disc degeneration, the panel recommends no change from the PEB determination as not unfitting. 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	5242	10%	

2	PD-2020-00050

DEPARTMENT OF THE NAVY
SECRETARY OF TIIE NAVY COUNCIL  OF  REVIEW  BOARDS 72 0 KENNON STREET SE STE 3 09
WASHINGTON NAVY YARD, DC 20374-5023

IU 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 30 Jun 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 0% to 10% 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.
1.