DEPARTMENT OF THE NAVY

BOARD FOR CORRECTION OF NAVAL RECORD

S

2 NAVY ANNE

X

WASHINGTON DC 20370.510

0

JRE
Docket No: 1631-02
7 October 2002

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  
injustice were reviewed in accordance with administrative regulations and procedures
applicable to the proceedings of this Board.
consisted of your application, together with all material submitted in support thereof, your
naval record and applicable statutes, regulations and policies.

on 19 September 2002. Your allegations of error and

Documentary material considered by the Board

In this connection, the Board substantially concurred with the rationale of the

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.
hearing panel of the Physical Evaluation Board which considered your case on 16 November
2000, a copy of which is attached.
at that time, or that you became unfit prior to your release from active duty on 7 Febraury
2002.
It concluded that your failure to be found physically qualified for sea duty was
insufficient to demonstrate that you were unfit for further service. Accordingly, your
application has been denied. The names and votes of the members of the panel will be
furnished upon request.

The Board was not persuaded that you were unfit for duty

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  
material evidence or other matter not previously considered by the Board.
important to keep in mind that a presumption of regularity attaches to all official records.

and
In this regard, it   is

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

SAN DIEGO FORMAL HEARING RATIONALE

A medical board was held at Naval Hospital Corpus  
on 15 June 2000 with the following diagnoses:

Christi,  TX

Cubital carpal tunnel syndrome with bilateral numbness(3540)

1.
2. Cervical spondylosis with myelopathy (7211)
3. Musculoskeletal low back pain (7242)
4. Thoracic or lumbosacral neuritis or radiculitis, unspecified(7244)
5. Unequal leg length (acquired) (73681)

The Informal Physical Evaluation Board found the member unfit for duty
with 20% disability rating on 31 August 2000 under:

CAT I:

1. Musculoskeletal low back pain with negative MRI and CT
Myelogram with left radicular
with 10% disability;

findings (7242)  VA Code 5295

2. Status post anterior cervical diskectomy and fusion to
C5-C6 interval and  
C6-C7 interval VA Code 5290 with 10%
disability

CAT III

3. Status post  
Symptomatology

cubital  tunnel release with no change in

4. Leg length discrepancy(73681)

This member appeared before the Formal PEB on 16 November 2000
requesting to be found unfit for duty with   40% disability rating and
placement on TDRL.

Accepted documentary evidence consisted of:

,

- PEB Case File
’

Exhibit A 
Exhibit B 
Exhibit C
Exhibit D
Exhibit E 
Exhibit F 

letter of 06 NOV 2000

letter of 08 NOV 2000
edical Evidence

- Performance Evaluations
- Additional Medical Evidence

The member's medical board of 15 June 2000 makes multiple diagnoses
The member is asking for ratings for two conditions.
listed supra.
wishes a rating for limitation of motion in her cervical spine and a
rating for low back pain.
With regard to the member's complaint of limitation of motion in her
The member was
neck, the medical board focuses on her neck surgery.
first evaluated in June 1998 for complaints of neck pain with radicular

These will be addressed seriatim.

  as

She

Enclosure 

(1)

C5-C6 and 

C5-C6 and 

C6-C-7.

C6-C7 levels in early 2000.

The physical examination in the medical board indicated that her

The member eventually was referred for cervical diskectomy

she was noted to have good healing with allograft

symptoms in the ulnar distribution along both hands.
showed some degenerative changes at  
herniated disks and arthritic changes with nerve root encroachment
that area.
and fusion of the  
the medical board,
bone.
bilateral upper extremities revealed negative Spurling and Lhermitte
signs.
complained of decreased sensation,
nerve distribution in her hands.
nerve in the right being  
her motor exam was intact at  
asymmetry or muscle wasting in the ulnar nerve distribution.
no reports of abnormal EMGS in the record.

Her reflexes were symmetric and within normal limits.

right greater than left in the ulnar
She had some weakness in the ulnar

There's no report of any muscle

4/5+ and the left being  

5/5-t.

Her initial x-rays
An MRI showed

  in

At the time of

The member

5/5+.

The remainder of

There were

However there's no indication in the medical board that

The member was wearing a cervical collar and said she has been wearing
this since 1998.
she needs to be wearing this cervical collar.
evidence in the form of a June 30th 2000 note from her private orthopod
indicates that the member's repeat MRI was noted to be normal as read
both by the orthopod and a radiologist.
that he felt the member had some residual "myofascial" pain but offered
no indication of any other abnormality.

The orthopod closed by saying

Additional medical

The member complained of some muscle spasms in her shoulders, but these
are not documented in any recent notes or additional medical evidence
contained in Exhibit F.
The member offered no assertions of how the
range of motion in her neck would significantly interfere with her
ability to carry out the duties of her rate.
difficulty of working as an IC on a ship, the member said she couldn't
pull cables with her arms over her head because of pain, but there was no
reference to any problem with range of motion in her neck.
physical examination of the member's upper extremities does not indicate
any significant weakness or even any other radiculopathy with pain
complaint'referable to the member's neck.
to the member's neck suggests that she has had very successful cervical
surgery. The first mention of any measure of range of motion is in
Exhibit 
simply notes that the member had limited range of motion in her neck.
But there's no suggestion that this limitation of motion in any way
significantly interferes with the member's ability to carry out the
duties of her rank and rate.

F in a hand written note of 25 October 2000.

When asked about the

The medical board

All the information with regard

Moreover, the

the medical board diagnosis
With respect to the member's low back pain,
is "musculoskeletal low back pain with negative MRI and CT myelogram with
left radicular findings".
The physical
of pain with absolutely no objective data to support it.
examination of the member's lower extremities contained in the medical
board notes
The straigh

only a leg length discrepancy of
t leg raise was reported as negat

approximately 1.5 to 2 cm.
The motor
ive bilaterally.

In fact, the member has a subjective complaint

Enclosure 

(1)

2

sensation intact to light touch to all

and reflexes 

2/4+ and symmetric.

5/5+ in all motor groups,

n,eed to walk with a cane.

exam was 
The member
dermatomal distributions,
but there's nothing in the
claimed that she needed to walk with a cane,
The
medical board to suggest why she would  
member also complained of subjective pain in her low back which she said
it made her difficult for her to sit for long periods of time.
member has been on 4-hour duty for the last two years, but there's no
substantiation in the medical board about why the member cannot work for
8 hours.
The member offered no assertion of why she could not carry out
the duties of her rank and rate as an IC because of her low back pain.
The member stated that she
Her job does not require prolonged sitting.
would have difficulty lifting things because of her cane, but her cane is
The
not indicated anywhere in the medical record as being necessary.
member said that she is
supported by her performance evaluation which indicates that she has been
doing adequate job while working in an office environment.

"not viable in the office", but this is not

The

The member proclaimed dramatic

However,

Additionally,

the objective data do not support
The

but there's no evidence in the medical
The member's dramatic pain

In sum, the member wants ratings for decreased range of motion in her
neck, but offered no evidence that the range of motion in her neck would
significantly interfere with duties.
complaints of pain in various parts of her body, but wishes a rating
specifically for her back.
any organic cause of the member's subjective complaints of pain.
member is walking with a cane,
board that she needs to walk.with a cane.
complaints are out of proportion to any objective data in the medical
record.
carpal tunnel syndrome with bilateral numbness which has been reviewed
carefully by the Formal Board and not found to be a separately unfitting
condition.
myelopathy,
surgery.
neuritis or radiculitis unspecified but there's no indication that is a
separately unfitting condition.
length, but there's no indication that this is separately unfitting
condition.
evidence, the Formal Board finds that the member is fit for continued
naval service.

The member has a diagnosis of cervical spondylosis with
but there's no evidence that this currently exists since her

The member also has a diagnosis of thoracic or lumbosacral

the member had several other diagnoses including

Therefore after careful consideration of all relevant medical

The member is noted to have unequal leg

Enclosure (1)