DEPARTMENT OF THE NAVY

BOARD FOR CORRECTION OF NAVAL RECORD

S

2 NAVY ANNE

X

WASHINGTON DC 20370-510

0

Docket No: 8040-99
29 January 2001

This is in reference to your application for correction of your naval record pursuant to the
provisions of title 10 of the United States Code, section 1552.

A three-member panel of the Board for Correction of Naval Records, sitting in executive
session, considered your application on 25 January 2001. Your allegations of error and
injustice were reviewed in accordance with administrative regulations and procedures
applicable to the proceedings of this Board. Documentary material considered by the Board
consisted of your application, together with all material submitted in support thereof, your
naval record and applicable statutes, regulations and policies. In addition, the Board
considered the advisory opinion furnished by a designee of the Specialty Leader for
Orthopedic Surgery. dated 24 December 2000, a copy of which is attached, and your
response thereto.

After careful and conscientious consideration of the entire record, the Board found that the
evidence submitted was insufficient to establish the existence of probable material error or
injustice.
in the advisory opinion.
disability at the time of your discharge from the Marine Corps. Accordingly, your 
b’
application has been denied, The names and votes of the members of the panel will be
furnished upon request.

In this connection, the Board substantially concurred with the comments contained
It was unable to conclude that you were unfit by reason of physical

It is regretted that the circumstances of your case are such that favorable action cannot be
taken. You are entitled to have the Board reconsider its decision upon submission of new
and material evidence or other matter not previously considered by the Board. In this
regard, it is important to keep in mind that a presumption of regularity attaches to all official

records. Consequently, when applying for a correction of an official naval record, the
burden is on the applicant to demonstrate the existence of probable material error or
injustice.

Sincerely,

W. DEAN PFEIFFER
Executive Director

Enclosure

Department of Orthopaedic Surgery

Naval Medical Center San Diego, Suite 112

34800 Bob Wilson Drive

San Diego, California 92134-1112

(619) 532-8427, -8429 

/ (619) 532-8467 Fax

24 

Dee 00

From: Director Orthopaedic Spine Service and Department Chairman

Naval Medical Center San Diego CA 92 134-5000
Chairman, Board for Correction of Naval Records

To:
VIA: Captain Dana Covey, Specialty Advisor for 
Subj: 

;

Orthopaedics

[Docket No 

8040-991

1.

2.

3.
.

.

.

.

.

.

.

ncluding the VA
ing the 

I have personally prepared this report after reviewing (in depth) the records
forwarded in the case of form
documentation and 
medical-
active duty.
mequested via DDF 149, dated 02 December 1999 that his
record be changed  “to a medical discharge and retire; ” and that he was “in a
light duty status 2 years prior to discharge because of my back. I refused
surgery for my back
VA documentation an
review only addresses the back and neck.
The following notations refer to extractions from the medical record:

d have been retired. ” Because of the
statement “because of my back,” this

SNM’s period of

F/U after MVA from 14 January 1995, 

95-c/0 continued backpain, headaches and
”

88/93 he checked positive for recurrent back pain. The
“ S/P MVA-Jan 

From his discharge history and physical 17 April 1996: the patient reports  “my
back hurts off and on-still have back spasms. ” The doctor noted,  “1 year s/p
motor vehicle injury, chronic LBP and HA+ whiplash injury.
A patient DDF 2697 entry by the patient: Back and neck pain-can ’t carry a
full pack on my back-to heavy and (can ’t) carry a machinegun
From 12 Sept 1995 
doctor annotated,  
neck pain-continues traction with physical therapy and ortho (treatment).
18 Jan 1995: 
rear-ended-twice-
complained of neck pain and tingling; mentioned mid and low back pain.
Treated with light duty, medications and heat.
TAMC ER 25 January 1995: Arrived by ambulance  “1 week post MVA” with
primary complaint of headache for which he received a CT scan. Mentioned
was LBP since MVA. Treated with Flexeril, Motrin and light duty.
July 95: Physical therapy. Mentions paraspinal bulges, cervical and lumbar.
Seen 10 July for headache and neck stiffness.  “I don’t have the pain in my left
arm and shoulder anymore ” Treated with SIQ and medication. 12 July was
seen by physical medicine consultant for trunk and neck pain; notes that MRI
showed multiple herniated discs. Diagnosis was myofascial pain syndrome.
Treatment was strengthening, aerobic conditioning and Elavil.
Earlier notes: 1988 F/U at 

NHCamp LJ -LBP/strain after a fall onto his back.

Bah  
Pediatric 

Bathgate,

 MD.

Otihopaedics

Booher
Kermit R  
CApT  MC, VSNR
General 

orlhqmedics  4

Julia C Buck, RN.
LCDR, NC, USN
Orchopwdics

 Division 

Oficer

Coni&  DPM

Michael A. 
LT,  
P&i&y

MSC,  USN

DM,  M.D.

Khiem  D. 
LCD&  MC, USN
Had  

an+rMierovasc#dv

Dellahfaggiore,

Eqqenr  D. 
LCDR, MC, USN
Genaal  

Orthopaedics

 

Surg.

 M.D.

Gillingham  M.D.

Bruce  L. 
CDR, MC, USN
Pcdiabic  
Associate Program

Orihqmdics

 

Director

 M.D.

GlarlrLn,
Merrill 
LCDR,  MC, USN
General 

Orihopaedics

Han&k

Lnnm  
Physician 

Assislml

Michael 
LCDR, 
General  

Langworthy,
hfC,  USN
Orthopoedics

 M.D.

 and Trauma

Lqoinl,  M.D.

John M. 
CApr.  MC, USN
Surguy
Shoiddu  

 M.D.

Manm,
Richard 
LCDR,  MC, USN
Spine 
lhofhy
CDR, MC, VSNR
Spo&  

Surgery
S  

 

M&gnu?,

 M.D.

Me&&e  and Knee 

Surgery

McClaq,

I+t  
MSC,  USN

Raymond 
LT. 
POdiiUYy

 DPM

1.  McDermott, M.D.

 

Michael
LCDR, MC, USN
Gcneml

 

Orihopaedics

Muldoon,

Michael P. 
CDR, MC, USN
A&d: 
ficc  

Reconstictive
Choinnan

 M. D

 

Surguy

T.  Nelson.

Fred  
Major Joint 

Scrvicc

 

M.D,

Alaamler
CDR(Sd),
Hand 

and  

I! Shin, M.D.
 
 MC USN
Micrmwgay.

 M.D.

F.  

Siller,
David 
CDR. MC, USN
Low.7 

Erlrendty  

surguy

S Webster. M.D.
 MC, USN

John 
C4pT.
Chaiim
Raidency  
Adull  Spine 

Rogmm  
Surgery

Direclor

Department of  

 Surgery
Naval Medical Center San Diego, Suite 112

Orthopaedic

34800 Bob Wilson Drive

San Diego, California 92134-l 112

(619) 532-8427, -8429 

/ (619) 532-8467 Fax

Subj:

Machinegunner, Infantry

.

4.

5.

6.
.

NavCare after falling onto back

1980-Lumbar  pain and stomach pain
1990-reported back spasm from auto accident occurring Sept 3rd. Civilian

8188 Back sprain treated at 
July 
Dee 
3 
care by physical therapy for  “mechanical LBP ” treated with medication and requested
report from civilian  
17 Sept 1990  “hit from behind ” in 
“shoulder pain ”

MVA” complaining of headache, backache and

ortho (no report seen)

Regarding the  17 April 1996 history and physical
qualified for discharge on his final physical exam
patient ’s note about not being able to carry his full pack or machine gun and
stating, “my back hurts off and on and still have back spasms
Follow-up: Apparently, the patient went on to have back surgery, fusion after
leaving the USMC and difficulty or inability to return to his job as a letter carrier
in the early post-operative period. This was apparently for sciatica, although none
of those records were provided.
Conclusions and Opinion:

found the SNM
was despite the

”

nfit at the time of his

It is highly unlikely that a PEB would have foun
discharge physical examination, based on the available record and with exclusive
focus on the low back pain or neck pain complaints.
However, with consideration of back pain, severe headaches, neck pain, ankle and
knee pain, wrist pain and his other problems, it is difficult to conclude that he was fit
and able to do his duties as a machine gunner in the infantry. On the other hand, his
doctors in September, 1995 and April, 1996 found him fit to re-enlist and for
discharge, respectively, these with doctor and patient notes acknowledging the back
pain problem.
Given the course of events, with worsening of back problem, development of sciatica
(not mentioned in the records I reviewed), he clearly would not have been able to
complete a 20-year career. If progression of disease and eventual outcome are to be
considered, rather than his symptoms, record and complaints at the time of discharge,
his request is reasonable.
There is no doubt that the record substantiates the claim of service connectivity and
If the patient had included records of his
significant level of low back complaints.
outside evaluations and MRI (presumably done in response to his MVA and possibly
to litigation) more could be said about his level of symptoms and/or disability at the
time of discharge from the USMC. The record acknowledges a moderate level of
symptoms at the time of discharge. The final outcome was of increasing symptoms

Bathgate,

Bdh 
Pedin@ic  

Otihopaedics

 MD.

Ken&R  
CAPT.
GeneraI  

Booher
MC0  VSNR
Orihopaaiics

 

Julia C Buck, RN.
LCDR  NC, USN
Orthop&  Division 

O/ficcr

 

Conti,

 DPM

MichaelA.
LT,  
POdi&y

MSC,  USN

Dao,  M.D.

MC0  USN

Khiem D. 
LCDR, 
Hand and 

Micmwcular  

DrllaMa&oree,

Eugene  D. 
LCDR,  MC, USN
General  

Orthqxedics

Surg

 MD.

CUingham,

 M.D.

Bruce L 
CDR, MC, USN
Pedi&ic  
Associate 

Orthopaedics
Pmgmm  

Dir&or

 Gladden, M.D.

Marill
LCDR, MC, USN
General 

Orihqwdics

Lauren  
Nurse 

Gmeuisch,
Cowdinator

 

RN,  BSN

Hanzlick

Laura  
Physician 

Asi.&m

Kupfer

Fncd  
Physician Assistant

Lnngwvihy,

Michael 
LCDR, MC, USN
Gaeral  

Orthopaedics

 M.D.

 and 

Trauma

l&win&  M.D.

John M. 
CAPT.
 
MC  USN
ShoulderSqay

 M.D.

M,wws,

Richard 
LCD&  MC, USN
spine 

swgay

Molagne,

S 

Timothy 
CDR. MC, VSNR
Sports  

Mulicine

 M.D.
 and  Knee 

Svgery

M&lay,

K 
MSC,  USN

Raymond 
LT,  
POdi<ly

 DPM

McDermoq  M.D.

1.  

Michael 
LCDR, MC, USN
General

 

Orthopaedics

P. 

Muldoon,

Michael 
CDR, MC, USN
A&t  Reconstructive 
yiee  Chairman

 M.D.

Surgrry

T.  

N&on,

Fred  
Mnjor  Joint Service

 M.D.

Alaander
CDR(Sel),
Hnnrl  and 

Y. Shin, M.D.
 
 MC, USN
Miimswgay.

Sider,  M.D.

F. 

David 
CDR  MC USN
Lmver  

Edrendty  

swgeq

 M.D.

S 

Webster,
Jokn  
&4pI,  MC, USN
Ch&man
Residency  
Ad&  Spine 

F+qram  Director

Surgery