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AF | PDBR | CY2014 | PD 2014 01046
Original file (PD 2014 01046.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX     CASE: PD-2014-01046
BRANCH OF SERVICE: NAVY  BOARD DATE: 20141204
SEPARATION DATE: 20080918


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PO2/E-5 (IT2/Information Systems Technician) medically separated for a back condition. The back condition could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards. He was placed on limited duty and referred for a Medical Evaluation Board (MEB). The back condition, characterized as “neuralgia, neuritis and radiculitis” and “displacement of lumbar intervertebral disc without myelopathy,” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB. The Informal PEB (IPEB) found the CI to be “Fit” to continue on Active Duty status. The CI requested and was granted a reconsideration of IPEB’s proceedings. The Reconsideration IPEB adjudicated the back condition “recurrent left S-1 radiculopathy” as unfitting, rated at 20%. The remaining condition w as determined to be a C ategory II . The CI made no further appeals and was medically separated.


CI CONTENTION: The CI elaborated no specific contention in his application.


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting back condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Naval Records.


 RATING COMPARISON :

Service Recon IPEB – Dated 20080620
 VA - (5 Mos. Pre -Separation)
Condition
 Code Rating Condition Code Rating Exam
Recurrent Lt S-1 Radiculopathy 5243-8520 20% Lt L-5 Radiculopathy assoc w/ L5-S1 Herniated Disc, S/P Microdiskectomy 8520 20% 20080425
Recurrent L5-S1 Herniated Disc CAT II L5-S1 Herniated Disc s/p Microdiskectomy 5237 10% 20080405
Other x 0 (Not In Scope)
 Other x 1
Combined: 20%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 80929 (most proximate to date of separation )


ANALYSIS SUMMARY:

Left Radiculopathy Condition. The narrative summary (NARSUM) notes the CI developed back with associated numbness/tingling in his left foot and weakness of his left leg in December 2005 after lifting. A magnetic resonance imaging (MRI) obtained in February 2006, revealed a large disc in the lower spine area with significant compression of the spinal nerve root. A neurosurgical evaluation on 13 March 2006, documented pain and decreased strength in the left lower leg, with atrophy of the left calf, loss of the left ankle reflex (Achilles reflex) and decreased sensation in the foot. The CI reported no loss of bowel or bladder function at this time. Surgical removal of the disc without laminectomy (micro discectomy) was performed on 23 March 2006; it was noted that the nerve root was “completely” decompressed (freed). On follow-up evaluations in April and August 2006, the leg pain had completely resolved, leg strength had returned and the CI was regaining the muscle bulk in his left calf. In September 2006, the leg pain, weakness and numbness returned after resumption of physical activity. On neurosurgical evaluation performed on 16 November, the CI had continued numbness in his foot but good foot and toe strength. He was able to do repeat toe stands. A repeat MRI revealed recurrence of the previously removed disc with spinal nerve root compression although “not as severe as last time.” The CI and his neurosurgeon opted to “forego a second surgical procedure.” On an anesthesia evaluation on 18 June 2007, the CI reported low back pain without back spasm. On examination, right and left leg strengths and ankle reflexes were equal bilaterally. The spinal scar was well healed.

At the MEB NARSUM evaluation performed on 4 March 2008 (approximately 7 months prior to separation), the CI reported sharp shooting pain down his back with numbness and tingling in his left foot. He noted this pain was tolerable and he did not wish further surgery. No report was made of leg weakness. On physical examination, a slight limp favoring the left was present. Range-of-motion (ROM) of the back was forward flexion (FF) of 80 degrees with pain and spinal muscle spasm and a combined spinal ROM of 155 degrees (normal, 90 degrees and 240 degrees). Motor strength in the left leg was +4/5 compared to 5/5 in the right leg. The left Achilles reflex was absent; and “tone” and bulk in the left calf was decreased. Muscle coordination of the leg with rapid repeat, alternating movements was normal.

At the VA Compensation and Pension exam performed on 25 April 2008 (5 months prior to separation), the CI reported continued back pain and shooting pains in his left leg, but no leg weakness. He noted an increase in mass and strength of the calf with physical therapy (atrophy improved) and his “back pain” to have no effect on his usual daily activity or occupation. On physical exam, the gait was normal. ROM of the back was FF 80 degrees; combined ROM was 205 degrees, without spasm but with pain on repetitive motion. Motor strength was 5/5 in both legs. The left ankle reflex was absent; and a slight decrease in light touch sensation was present on the top of the right foot. Measurements of the calf circumference were 39 cm (right) and 41 cm (left). Measurements of thighs were equal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB and VA both rated the neuropathy condition as 20%, using code 8520. (Sciatic nerve, incomplete paralysis /moderate). Under this code, a rating of 10% requires the condition to be mild; a 20% rating requires the condition to be moderate, and a 40% rating requires the condition to be moderately severe. The PEB adjudicated the herniated disc condition as a Category 2 diagnosis, not unfitting and not subject to rating. The VA adjudicated an additional rating for the herniated disc condition, 10%, coded 5237 (lumbar-sacral strain). A 10% rating under this code requires spinal flexion of greater than 60 degrees, but not greater than 85 degrees, or a combined spinal ROM of greater than 120 degrees but less than 235 degrees. A 20% rating requires flexion greater than 30 degrees, but not greater than 60 degrees or a combined spinal ROM of not greater than 120 degrees.

The Board noted the PEB’s adjudication for the radiculopathy condition. Major symptoms of the neuropathy in the record were: radiating leg pain, decreased sensation on the dorsum of the left foot, atrophy of the left calf muscle and left leg weakness. The Board unanimously agreed the radiating leg pain was subsumed under the back condition as discussed below. The absent Achilles reflex and decreased sensation of the foot had no functional significance. The muscle atrophy of the left calf with leg weakness was improving with physical therapy treatment and was mild at separation given the minor/normal gait, mild/absent motor weakness, miniscule differences in calf muscle mass measurement, and lack of demonstrated impact of leg function on operational/functional activity in proximate evaluations referenced above. The Board unanimously agreed the record in evidence supported the neuropathy to be mild and to warrant a 10% rating, coded 8520 and no higher. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the neuropathy condition.

The Board agreed the CI had a radiculopathy and this was caused by a significant and symptomatic spinal disc condition. The Board opined that the major symptoms at separation were back pain with radiation to the leg given the minor findings discussed above. On review the Board unanimously agreed the predominance of evidence in record supported the back/disc condition, determined by the PEB to be a Category 2 condition, was indeed an unfitting condition per se and subject to rating consideration.

The Board undertook a rating for the back condition. The Board unanimously agreed the record referenced above supported a rating of 10% for the back condition for reduced ROM of 80 degrees coded 5243 (disc syndrome) on examinations proximate to separation. The record supported no higher rating under this code. The Board agreed the record did not support a rating under code 5242 (incapacitating episodes). The Board found no other appropriate codes for consideration for the back condition. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the back condition. In summary the Board recommends a 10% rating for the back condition and a 10% rating for the neuropathy condition, for a combined rating of 20%. As this provides no rating benefit to the CI, the Board, under precedent, recommends no change in the PEB adjudication.


BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the neuropathy condition, the Board unanimously recommends a disability rating of 20%, coded 8250 IAW VASRD §4.123. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.
The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140225, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





XXXXXXXXXXXXXX
President
Physical Disability Board of Review






         MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
BOARDS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) CORB ltr dtd 29 Apr 15

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:
- XXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USN


                                                      XXXXXXXXXXXXXX
                                            Assistant General Counsel
                                                      (Manpower & Reserve Affairs)
                          

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