RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX 		                     BRANCH OF SERVICE:  army
CASE NUMBER:  PD1100493		                      SEPARATION DATE:  20050104
BOARD DATE:  20120109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty member, SGT/E-5 (25Q20/Multichannel Transmission Systems Operator/Maintainer), medically separated for left sacroiliac (SI) joint dysfunction with left hip pain.  The CI’s low back pain with radiation to his left leg began after lifting equipment in 2003 (he lifted a metal table top over his head).  MRI revealed two-level degenerative disc disease (DDD) with L4-5 impinging the central canal.  His treatment included medications (including narcotics), physical therapy (including TENS), chiropractic manipulation, epidural steroid injections, and surgery (L4-S1 fusion in February 2004).  He did not respond adequately to treatment and was unable to perform within his Military Occupational Specialty (MOS) or meet physical fitness standards.  He was issued a permanent P3 and underwent a Medical Evaluation Board (MEB).  Left sacroiliac joint dysfunction and left hip pain were forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501.  No other conditions appeared on the MEB’s submission.  Other conditions included in the Disability Evaluation System (DES) file are discussed below.  The Informal PEB (IPEB) combined the two conditions, and adjudicated the left sacroiliac joint dysfunction with left hip pain condition as unfitting, rated 10%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy and/or AR 635-40 (B.24 f.).  The CI did not appeal for a formal PEB, and was medically separated with a 10% disability rating.

CI CONTENTION:  “Not all medical reasons was [sic] considered for disability.  Also VA disability rating was not considered for Army disability rating.  Original rating was told to me by a E-7 sergeant that if I challenged the rating the Army gave me then I would lose the 10% that was granted to me.  Original rating paperwork [is] on file with the VA in Bonham Texas.”  He elaborates no specific contentions regarding rating or coding and mentions no additionally contended conditions.  All service conditions are reviewed by the Board for their potential contribution to its rating recommendations.

RATING COMPARISON:  

Service IPEB – Dated 20041022	VA (~1 Mo. After Separation) – All Effective Date 20050105	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Sacroiliac Joint Dysfunction With Left Hip Pain	5236	10%	Lumbar Spine Injury, S/P Discectomy W/ Fusion L4-S1 …	5243	20%	STR 	
			Radiculopathy, Left Sacroiliac Joint Dysfunction … 	8599-8520	10%	STR	
↓No Additional MEB/PEB Entries↓	Hypertension	7101	10%	STR	
	0% x 5/Not Service Connected x 0	20041012	
Combined:  10%	Combined:  40%	

ANALYSIS SUMMARY:  The Board acknowledges the CI’s contention that suggests service ratings should have been conferred for other conditions documented at the time of separation.  The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates.  While the DES considers all of the service member's medical conditions, compensation can only be offered for those medical conditions that cut short a service member’s career, and then only to the degree of severity present at the time of final disposition.  However the Department of Veterans’ Affairs (DVA), operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service connected conditions and to periodically reevaluate said conditions for the purpose of adjusting the Veteran’s disability rating should his degree of impairment vary over time.

The PEB combined lumbosacral and left hip conditions as a single unfitting condition, coded as 5236 (sacroiliac injury and weakness), and rated 10%.  The PEB may have relied on AR 635-40 (B.24 f.) and/or the USAPDA pain policy for not applying separately compensable VASRD codes.  However, it was most likely that the left hip pain was radicular pain from the lumbosacral condition.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases, it must satisfy the requirement that each “unbundled” condition was unfitting in and of itself.  This approach by the PEB reflects its judgment that the constellation of conditions was unfitting, and that there was no need for separate fitness adjudications, not a judgment that each condition was independently unfitting.  Thus, the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB. 

Left SI Joint Dysfunction.  The Board first considered if left SI joint dysfunction, having been de-coupled from the combined PEB adjudication, remained independently unfitting as established above.  The SI joint dysfunction was apparently related and almost certainly served as a surrogate for the CI’s spine DDD and spine surgery (L4-S1 fusion 11 months pre-separation), as pain in the left hip and SI joint area were the CI’s predominate symptoms.  Both the permanent profile and commander’s statement directly implicate the lumbar spine or “back” injury or surgery (to the neglect of any SI joint involvement).  IAW VASRD 4.71a, the SI joint is evaluated under the General Rating Formula for Diseases and Injuries of the Spine, which considers the total disability of the thoracolumbar spine, so there is no need to attempt to apportion symptoms related to the SI joint versus those related to the lumbar spine.  All members agreed that thoracolumbar spine/left SI joint dysfunction, as an isolated condition, would have rendered the CI incapable of continued service within his MOS, and accordingly merits a separate service rating.

There were four lumbosacral spine exams, including two complete goniometric range-of-motion (ROM) evaluations, in evidence which the Board weighed in arriving at its rating recommendation.  All of these exams are summarized in the chart below.  

Goniometric ROM - Thoracolumbar	MEB (PT) ~ 7 Mo. Pre-Sep	NARSUM ~ 3 Mo. Pre-Sep	Pain Mgmt ~ 2 mos Pre-Sep	VA C&P ~ 1 Mo. Pre-Sep	
Flex (0-90)	(75⁰,75⁰,70⁰) 70⁰	No ROMs reported	45⁰	40⁰	
Ext (0-30)	(20⁰,20⁰,20⁰) 20⁰		10⁰	15⁰	
R Lat Flex (0-30)	(35⁰,40⁰,35⁰) 30⁰			25⁰	
L Lat Flex 0-30)	(40⁰,40⁰, 40⁰) 30⁰			25⁰	
R Rotation (0-30)	(35⁰,38⁰, 40⁰) 30⁰			30⁰	
L Rotation (0-30)	(25⁰,25⁰,30⁰) 25⁰			30⁰	
COMBINED (240)	205⁰			165⁰	
Comment:  
Surgery ~ 11 Mo. Pre-Sep	Limited by pain and represents pt’s willingness to move through pain; [4 mos post op]	TTP with axial compression of left SI joint, no motor or sensory deficits, DTR’s normal, SLR neg bilat, pos Patrick’s, pos Gaenslen’s on left, pain w/ internal rotation of left hip	Antalgic gait, TTP, pos facet load L>R, motor 5/5, painful on heels & toes, DTR’s (knees +1 bilat., ankle absent on left), pos Patrick’s, pos Gaenslen’s, neg SLR	Painful motion, diminished sensory (LT) left hip, normal posture & gait w/o assistive device, motor normal, no atrophy, reflexes + 2 at knees bilat, repeated and resisted motion did not further limit ROM or function, SLR neg, able to heel –toe walk w/o difficulty, Waddell’s neg	
§4.71a Rating	10%	N/A	20%	20%	

ROMs recorded by physical therapy seven months pre-separation (four months post-operative) revealed limitations and painful motion meeting the 10% criteria IAW the General Rating Formula for Diseases and Injuries of the Spine, VASRD §4.71a.  The MEB DD Form 2808, six months pre-separation, did not provide ROMs but noted a healed lumbar scar with some tenderness, positive straight leg raises at 70° on the right and 45° on the left, and the CI was able to heel- and toe-walk.  The narrative summary (NARSUM), three months pre-separation, reported tenderness to palpation with axial compression of the left SI joint, positive tests for SI joint dysfunction (Patrick’s and Gaenslen’s tests), and pain with internal rotation of the left hip (see hip discussion below).  The exam was otherwise normal, with no motor or sensory deficits, normal reflexes, and negative straight leg raises bilaterally.  No post-operative MRI was of record.  Lumbar spine radiographs revealed intact implants and good intervertebral fusion mass.  An outpatient clinical entry three months pre-separation, the day prior to the IPEB (not included in above chart for brevity), reported the CI fell in his home, reinjuring his back, exacerbating his pain, and causing reduced ROMs in all planes (no quantitative measurements).  An outpatient entry from pain management two months pre-separation (10 days after the IPEB), reported significantly reduced flexion and extension (flexion meeting the 20% criteria under the General Rating Formula), antalgic gait, tenderness, positive facet loading test (left greater than right), positive Patrick’s and Gaenslen’s tests (for SI joint dysfunction), painful walking on heels and toes, and abnormal reflexes (knee reflexes reduced bilaterally, ankle reflex absent on left).  Normal findings included 5/5 motor, and negative straight leg raises.  The new diagnosis was failed back syndrome and the CI was continued on narcotic pain management.

The VA exam one month pre-separation, reported similarly reduced ROMS (meeting the 20% criteria), painful motion, and diminished sensation to light touch over left hip.  The remainder of the exam was normal, with normal posture and gait without assistive device, normal motor function, no atrophy, reflexes normal (+2) at knees bilaterally, and negative straight leg raises.  The CI was able to heel-and-toe walk without difficulty, and repeated and resisted motion did not further limit ROM or function.  The examiner noted the absence of Waddell’s or other non-organic signs.  In addition to the lumbar spine injury status post discectomy and fusion L4-S1, the examiner diagnosed “residue of nerve injury of L5 and S1, most likely secondary to the lumbar spine injury.”  

There were no reports of incapacitating episodes requiring bed rest prescribed by a physician and treatment by a physician, as required for rating under intervertebral disc syndrome, so the condition is most appropriately rated using the General Rating Formula for Diseases and Injuries of the Spine.  Because of the multiple spine pathologies, including DDD status post discectomy and fusion, as well as SI joint involvement indicated by positive Patrick’s and Gaenslen’s tests and CI complaints of “hip” pain, the most appropriate coding is analogous to a combined 5243 (Intervertebral disc syndrome) to include fusion, with 5236, sacroiliac injury and weakness.  The Board considered the common post-surgical improvement of back ROMs, the CI’s pre-separation re-injury of his back and the sustained decreased ROM pre-separation.  The two exams most proximate to separation would rate 20% IAW the General Rating Formula by ROM and include radicular pain.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separation rating of 20% for the left SI joint and spine condition.  

LBP Condition (Radiculopathy).  There was no evidence of unfitting peripheral nerve impairment in this case.  The CI endorsed hip pain (see below) and episodic radiation of pain into his legs (particularly the left), and episodic left leg numbness, but no leg weakness.  Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation.  The pain component of a radiculopathy is subsumed under the CI’s primary unfitting lumbosacral condition as specified in §4.71a IAW the General Rating Formula for Diseases and Injuries of the Spine, “With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.”  The PEB noted the condition was “without neurologic abnormality….”  An electrodiagnostic study performed three months pre-separation (3 weeks prior to the NARSUM) identified left L5 and S1 radiculopathies, evidenced by spontaneous EMG activity in several left sided muscle groups.  The NARSUM exam found no clinical evidence of a non-pain radiculopathy.  The single exam which reported diminished reflexes (pain management note, two months pre-separation), was followed by the pre-separation VA C&P exam which documented normal reflexes.  The VA exam noted sensory deficit to light touch over the left hip.  A very detailed pain management evaluation two months post-separation documented abnormal gait, decreased (4/5) left leg knee flexion strength, normal reflexes, and CI-reported paresthesias along the L5-S1 distribution in the lower leg and lateral foot.  None of the pre-separation exams in the record noted any motor deficits, atrophy, or foot drop.  The pre-separation report of abnormal gait (antalgic gait at pain management visit two months pre-separation) was most likely due to pain, as the motor evaluations were normal.  The post-separation abnormal gait was matched with left leg motor weakness.  The motor impairment was therefore either intermittent [if absent reflex is considered] or relatively minor and cannot be linked to significant physical impairment.  Since no evidence of functional impairment exists in this case, the Board cannot support a recommendation for additional rating based on peripheral nerve impairment.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting addition of any lower extremity radiculopathy as an unfitting condition for separation rating.

Left Hip Pain Condition.  As previously elaborated, the Board must first consider whether left hip pain remains separately unfitting, having de-coupled it from a combined PEB adjudication.  There was no evidence of left hip trauma or joint pathology.  The most likely cause of the CI’s hip pain was SI joint dysfunction or radicular pain which was considered under the CI’s primary unfitting condition.  In analyzing the intrinsic impairment for appropriately coding and rating the left hip pain condition, the Board is left with a questionable basis for arguing that left hip pain was indeed independently unfitting.  The commander’s statement and permanent profile did not identify hip pain, and only referenced the CI’s back condition.  The service treatment record did not reveal any hip injury or outpatient visits related to hip pain.  There were no detailed hip joint evaluations, with the only reference being the NARSUM’s “pain with internal rotation of the left hip.”  This was noted in the same sentence as the positive SI joint tests, and it is possible that SI joint pain was elicited by internal hip rotation.  There were no hip radiographs or other evidence of hip pathology in the record.  After due deliberation, the Board agreed that evidence does not support a conclusion that left hip pain, as an isolated condition, would have rendered the CI incapable of continued service within his MOS, and accordingly cannot recommend a separate service rating for it.

Remaining Conditions.  Other conditions identified in the DES file were hypertension (VA 10%), hypertriglyceridemia, macrocytosis (“no anemia noted”), cervical degenerative disc disease and degenerative joint disease, one episode of bronchitis, left knee pain (associated with blunt trauma, none now), ankle pain (unspecified side), headaches (two types), and sinusitis.  Several additional non-acute conditions or medical complaints were also documented.  None of these conditions were occupationally significant during the MEB period, none carried attached profiles and none were implicated in the commander’s statement.  These conditions were reviewed by the action officer and considered by the Board.  It was determined that none could be argued as unfitting and subject to separation rating.  No other conditions were service connected with a compensable rating by the VA within 12 months of separation or contended by the CI.  The Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating.

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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the combined left SI joint and left hip condition was likely operant in this case and the condition was adjudicated independently of that regulation and policy by the Board.  In the matter of the left SI joint dysfunction with left hip pain condition, the Board unanimously recommends that it be adjudicated as two separate condition as follows:  an unfitting left SI joint dysfunction, status-post fusion L4-S1 condition coded 5243-5236 and rated 20% IAW VASRD §4.71a; and a not unfitting left hip pain condition.  In the matter of the hypertension condition or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Left SI Joint Dysfunction, S/P Fusion L4-S1, including Radicular Pain 	5243-5236	20%	
Left Hip Pain	Not Unfitting	
COMBINED	20%	
______________________________________________________________________________

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20110619, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans' Affairs Treatment Record

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl