RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX	CASE:  PD-2014-00343
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141023
SEPARATION DATE:  20071113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active SrA/E-4 (1C052/Aviation Resource MGT Journeyman) who was medically separated for chronic low back and hip pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued an L4 profile and referred for a Medical Evaluation Board (MEB).  The chronic low back and hip pain condition, characterized as “Chronic low back and hip pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic low back and hip pain” as unfitting, rated 10% with likely application of the Department of Defense Instruction (DoDI) 1332.39 and VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Pain at time of separation has gotten progressively worse.  I have been unable to keep a job or continue my education in the field of my dreams, nursing, due to the pain I endure daily.  During my time in the military, my PCM referred me to a civilian rheumatologist.  This rheumatologist suggested that I had a condition called Ankylosing Spondilitis [sic].  My PCM did no further research into what was wrong with me, and instead he diagnosed me with only chronic hip and low back pain.  I still do not know what is wrong with me, but I do know that my pain is excruciating.  My hips lock to the point of not being able to move, as well as my knees now too.  My back spasms to the point of debilitating me.  My doctors in the military gave me Tylenol with codeine for the pain, although I was never actually able to take this because it impaired my functions, and I was unable to do my duties as an airman.  To me it seemed as if my PCM's primary focus was on treating the pain, but instead maybe should have been focused on what was wrong with me, to be able to properly treat me, instead of trying a few procedures that were not meant for my young body, such as steroid injections or denervation.  When I saw the civilian rheumatologist, she had said that I should have not had those procedures done at such a young age, and that those procedures were more for the older population.  My VA doctor had me on Flexeril, this did nothing for my pain, it only made me sleepy and masked the pain.  Now my doctors have me on Tramadol, which generally does the same thing, but this time it makes the pain go away a little.  My time in the military was mostly spent on a medical profile, limiting my physical activity.  I was only able to stand for so long, sit for so long, no heavy lifting, pretty much no physical activity.  I was unable to deploy my entire time in the military due to my medical profile.  Upon my discharge from the military, I was rated at 10%, while about a year later the VA rated me at 30%.  I believe that I was poorly rated, due to me not having a proper diagnosis, and due to the fact that I'm unable to keep a job or to go to school like the average person.” 

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 chronic low back and hip pain 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 Military Records (BCMR).

The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her, but must emphasize that the military Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board also acknowledges the CI’s opinion that a medical error (improper diagnosis) contributed to her disability.  It is noted for the record that the Board has no jurisdiction to investigate or render opinions in reference to such allegations.  These issues may be addressed by the BCMR and/or the United States judiciary system.

RATING COMPARISON:

Service IPEB – Dated 20070905	VA - (5.5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back and Hip Pain	5237	10%	Right Hip Strain
	5024
	10%
	20080501	
			Left Hip Strain	5024	10%	20080501	
			Chronic Lumbar Strain	5237	10%	20080501	
Other x 0  (Not in Scope)	Other x 2 	20080501	
Combined:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20080917 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Low Back and Hip Pain.  Review of the available service treatment record (STR) showed a specialty evaluation in 2005 for a 2-year history of low back pain (LBP).  A diagnosis of inflammatory spinal arthritis (specifically, ankylosing spondylitis) was considered likely at that time because a blood test was positive for the presence of a suggestive immune marker (HLA-B27).  Injections of lumbosacral facet joints, sacroiliac joints and paraspinal muscle trigger points were not helpful for her back pain.  Bilateral lumbar denervation procedures and multi-modality physical therapy also did not alleviate back pain.  Careful review of the entire STR showed complaints of low back and hip pain, but no evidence of a formal diagnosis of a hip condition or of therapeutic interventions focused on the hips.

At a physical medicine clinic evaluation on 23 August 2006 (15 months prior to separation) the CI’s chief complaint was low back pain.  At a rheumatologist’s evaluation on 7 February 2007 (9 months prior to separation) the CI complained of low back and bilateral groin pain.  Examination showed the spine “moves well” and “evidence of irritability within her hips.”  Although consideration was given to the diagnosis of ankylosing spondylitis, confirmatory blood and radiologic testing was negative and in June 2007 (5 months prior to separation) the rheumatologist’s only diagnosis was “mechanical back pain.”  The commander’s statement on 13 July 2007 (4 months prior to separation) reported that the CI was assigned a normal duty schedule and showed “the ability to successfully perform well above duty requirements.”  However, her job was not physically demanding, and her condition rendered her not suitable for deployment.

The narrative summary evaluation prepared on 20 July 2007 (4 months prior to separation) noted the CI’s 3-year history of LBP and hip pain.  Pain was typically exacerbated by sitting and prolonged walking, while standing upright or a long hot shower relieved pain.  She stated that her condition did not interfere with her job, which involved only desk work; but she could not perform fitness training such as running, push-ups and sit-ups.  Physical exam showed full (but unmeasured) range-of-motion (ROM) in all extremities and “slight tenderness” of the sacro-iliac region bilaterally.  On the Report of Medical Assessment, the CI wrote that chronic low back and hip pain limited her ability to work in her “primary military specialty or require geographic or assignment limitations.”

At the VA Compensation and Pension (C&P) exam performed 5.5 months after separation, the examiner reported lumbar spine pain “constantly … now that she is pregnant.”  Prior to pregnancy, the pain occurred “multiple times during the day.  The pain does radiate to her hips.”  Flare ups of pain occurred every other day and lasted for 2 hours.  She did not use assistive devices for ambulation.  She denied physician-prescribed bed rest for LBP.  She could not lift more than 20-30 pounds, stand more than 15-20 minutes or sit for more than an hour.  The CI also complained of constant hip pain that, prior to her pregnancy, occurred every day.  The examiner did not describe features that distinguished this pain from the pain that radiated from her low back.  She denied functional limitations with walking, and she was working full time in security.  Examination showed a normal gait and spinal contour.  Repetitive spine motion did not result in additional limitation.  Hip tenderness was not mentioned, but there was no additional limitation with repetitive hip motion.  The examiner listed diagnoses of lumbar strain and bilateral hip strain.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	PT ~15 Mos. Pre-Sep	VA C&P ~ 5.5 Mos. Post-Sep	
Flexion (90 Normal)	90 (125)	90	
Extension (30)	30 (45)	30	
R Lat Flexion (30)	25 (26)	30	
L Lat Flexion (30)	15 (17)	30	
R Rotation (30)	Not Reported	30 (45)	
L Rotation (30)		30 (45)	
Combined (240)	N/A	240	
Comment	Painful motion	Painful flexion and lateral flexion; no tenderness or spasm	
§4.71a Rating	10%*	10%*	
		*Conceding painful motion (§4.59)

Hip (Thigh) ROM
(Degrees)	VA C&P ~ 5.5 Mos. Post-Sep	
	Left	Right	
Flexion (125 Normal)	125	125	
Extension (20)	20	20	
External Rotation (45)	60	60	
Abduction (0-45)	45	45	
Adduction (45)	25	25	
Comment	Painful flexion “at 145.”  Pain at terminal adduction, abduction and external rotation.	Pain at terminal adduction, abduction and external rotation.	
§4.71a Rating	10%*	10%*	
			*Conceding separately unfitting hip condition and painful motion (§4.59)

The Board directs attention to its rating recommendation based on the above evidence.  The PEB concluded that the unfitting condition existed prior to service, but was aggravated by service; and did not apply a deduction.  Compensable limitation of spine motion was not present, but Board members agreed there was sufficient evidence of painful motion (VASRD §4.59) to justify a 10% rating under the 5237 code (lumbosacral strain) used by the PEB and the VA.  There was no evidence of muscle spasm or guarding severe enough to cause abnormal gait or spinal contour, thus the next higher 20% rating was not supported.  The Board also considered rating intervertebral disc disease under the alternative formula for incapacitating episodes, but could not find sufficient evidence which would meet a minimal rating under that formula.  In this case, the CI reported a long history of hip pain, but the record did not indicate the presence of hip pathology, or of hip symptoms separate from the back pain condition.  Most clinical notes referred only to back pain and when hip pain was mentioned, it was only in association with back pain.  All treatment notes, including physical therapy and pain management entries, targeted the low back condition.  Sacroiliac pain (a location of pain in this case) commonly radiates to the hip and groin, while lumbar spine pain of any cause can radiate to the hips.  Groin pain was noted by the rheumatologist, while the C&P examiner confirmed the presence of back pain that radiated to the hips.  The final rheumatology note in evidence assigned only a diagnosis of mechanical LBP.  The Board concluded that the PEB, through its use of the 5237 code, regarded hip pain as a manifestation of the low back condition.  IAW VASRD §4.71a, rating low back conditions subsumes radiating pain since the general spine rating criteria specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore, separately rating bilateral hip pain in this case runs the considerable risk of pyramiding, which IAW with VASRD §4.14, is to be avoided.  The Board concluded therefore that hip pain was properly subsumed under back pain.  Even conceding the issue of a separate hip condition however, the well-established principle for fitness determinations is that they are performance-based.  The Board could not find evidence in the service treatment record that documented any significant interference of hip pain with the performance of duties at the time of separation, nor were there any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability.  The Board concluded therefore that if a hip condition separate from the spine condition was present, it could not be recommended for additional disability rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back and hip pain condition.

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 chronic low back and hip pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140103, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record
SAF/MRB

Dear XXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2014-00343.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,