RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-00417	
BRANCH OF SERVICE:  AIR FORCE  	 BOARD DATE: 20150324
SEPARATION DATE:  20070702		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Basic Trainee) medically separated for a pelvic fractures and transverse process fracture of L3 condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS) or satisfy physical fitness standards.  She was issued an L4 S3 profile and referred for a Medical Evaluation Board (MEB).  The following conditions (adjustment disorder with depression and anxiety, sleep disturbance, pelvic fracture pubis-closed, pelvic fracture acetabulum-closed, closed fracture lumbar vertebral body and pulmonary contusion) were, forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The informal PEB adjudicated “pelvic fractures and transverse process fracture of L3” as unfitting, rated 20%, citing criteria of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) and adjustment disorder with depression and anxiety as a Category III (not separately unfitting and not compensable or ratable) condition.  The CI made no appeals, and was medically separated.

CI CONTENTION:  “Condition was much worse than previously thought.  Chronic pain from this.  I have secondary conditions.  Pain in my lower back.  It hurts when I breathe.  I get migraines, insomnia, PTSD, depression.  Anxiety, memory loss, shortness of breath.  Psychological problems with stomach scars.  At the time of discharge, not all these conditions were realized.” [sic]

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:  
   
Service IPEB – Dated 20070517	VA - (4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pelvic Fractures and Transverse Process Fracture of L3	5235	20%	Transverse Process Fracture of L3	5237	40%	20071107	
			Pelvic Fracture	5010	10%	20071107	
Adjustment Disorder w/Depression and Anxiety	CAT III	PTSD w/Adjustment Disorder w/Mixed Depression and Anxiety	9411	50%*	20081231	
MEB/PEB Entries x 0	Other x 1	20071107	
Combined:  20%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20080205 (most proximate to date of separation [DOS]).  
*VARD 20090209 awarded 50% for PTSD w/Adjustment Disorder w/Mixed Depression and Anxiety effective 20080909.

ANALYSIS SUMMARY: 

Pelvic Fractures and Transverse Process Fracture of L3 Condition.  The CI was hit by a truck while walking on base to an appointment on 23 January 2007 and sustained a fractured pelvis (right inferior pubic ramus, right superior pubic ramus adjacent to the acetabulum, and the left ilium adjacent to left sacroiliac joint), and a fracture of the transverse process of the L3 vertebra.  Her injuries did not require surgery and were treated with rest and non-weight bearing followed by rehabilitation from 31 January 2007 to 20 March 2007.  Rehabilitation records recorded minimal to no pain by the end of the rehabilitation program.  Orthopedic examination on 28 March 2007 recorded absence of back pain; however, there was mild tenderness to palpation of the lumbar spine.  There was no pain or tenderness with hip motion.  The surgeon advised continued physical therapy.  Follow-up imaging (CT scan 6 April 2007) demonstrated healing pelvic fractures with normal alignment.  Physical therapy examination on 26 April 2007, recorded low back and sacral pain with limited range of back motion.  Hip mobility was normal but there was left hip pain at end of the range of flexion and external rotation.  On 7 May 2007, physical therapy performed a “lumbosacral” range-of-motion (ROM) examination using an inclinometer and recorded flexion 44 degrees, extension 10 degrees, left side bending 21 degrees, and right side bending 19 degrees.  Rotation was not tested “secondary to poor reliability.”  At an orthopedic surgery follow-up examination on 21 May 2007, the CI was observed to be walking normally without aides.  There was no pain with compression of pelvis, and no tenderness to palpation at the sacroiliac joint, the sciatic notch (adjacent to the posterior aspect of the pelvis) or the piriformis (adjacent to the inferior pubic ramus and ischium).  There was no hip tenderness.  There was good hip ROM without pain.  There was tenderness of the back at the L3-L4 level and pain with back motion.  Lower extremity strength and sensation was normal.  A physical therapy examination on 30 May 2007 recorded active thoracolumbar flexion with fingers reaching to the proximal tibia (below the knee; approximately 50 to 60 degrees), and side bending reaching the fingers to the lower thigh (approximately 20 degrees).  There was tenderness of the right sacrum, but no tenderness of the lumbar spine region.  Hip mobility was normal but pain of the left hip was noted with examination maneuvers which stressed the left sacroiliac joint region (FABER maneuver).  Physical therapy evaluation on 2 July 2007, the day of separation, recorded the same ROM and noted the left hip discomfort was no longer present with examination maneuvers (FABER).  An orthopedic examination on 11 July 2007 recorded improved back pain but still occasional pain with activities.  The examination was unchanged from 21 May 2007.  At the time of the VA compensation and pension (C&P) examination on 7 November 2007, 4 months after separation, the CI reported improved but persisting back and right anterior pelvis/hip pain.  She was not on any pain medications and performed stretching exercises now and then.  She reported low back pain with heavy lifting and carrying, and prolonged standing or walking.  On examination the gait and posture were normal.  Lower extremity strength was normal.  Hip motion was slightly limited in flexion equally in both hips with pain reported with right hip motion.  Spine flexion was to 30 degrees before onset of pain.  The examiner did not record flexion beyond the point of pain onset. There was no muscle spasm.  X-rays of the right hip showed an old healed fracture of the pubis bone of the pelvis but was otherwise normal (no abnormalities of the hip joint).  X-ray of the lumbosacral spine was normal (no fracture reported) and the examiner noted “currently no sign of L3 transverse process fracture”.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the pelvic fractures and transverse process fracture of L3 20% coded 5235 (vertebral fracture).  The VA rated the L3 fracture 40% based on the limitation of thoracolumbar motion at the time of the post-separation VA C&P examination and 10% for pelvic fracture based on report of right hip pain at the C&P examination.  Service treatment records prior to separation documented the predominant impairment was back pain attributable to the fracture of the L3 transverse process and fracture of the left ilium (posterior pelvis) adjacent to left sacroiliac joint.  In accordance with VASRD §4.66, the lumbosacral spine and sacroiliac joint are considered as one anatomic region for rating purposes.  The physical therapy ROM recorded on 7 May 2007 was specified as of the lumbosacral spine and not the thoracolumbar spine as required by the VASRD general rating formula for rating diseases and injuries of the spine, and was performed using an inclinometer method rather than goniometer.  The reported lumbosacral flexion of 44 degrees compares to the normal lumbosacral flexion of 60 degrees and is consistent with the relative limitation of thoracolumbar motion indicated by the subsequent physical therapy examinations.  Although the subsequent physical therapy examinations on 30 May 2007 and 2 July 2007 did not specify the thoracolumbar ROM in degrees, the detail of flexion with fingers reaching the proximal tibia (shin) past the knees (50 to 60 degrees) and side bending with fingers reaching the lower thigh (approximately 20 degrees) clearly describes thoracolumbar motion rather than isolated lumbosacral motion.  The limitation of thoracolumbar motion at these two physical therapy examinations (flexion not greater than 60 degrees) support the 20% rating adjudicated by the PEB.  The post-separation VA C&P examination recorded limitation of thoracolumbar motion which supported the VA’s 40% rating.  The Board however concluded that this examination was not consistent with the known pathology and the results of the other examinations proximate to separation.  The Board next considered if an additional rating was warranted for hip impairment due to the pelvic fractures.  Service treatment records documented significant low back pain with limitation of back motion associated with the fracture of the L3 transverse process and fracture of the left posterior pelvis (left ilium adjacent to left sacroiliac joint).  There was discomfort with left hip maneuvers, which stressed the left sacroiliac joint region.  In accordance with VASRD §4.66, the lumbosacral spine and sacroiliac joint are considered as one anatomic region for rating purposes.  In addition, the left hip discomfort with examination maneuvers was absent at the time of separation and there was no direct injury or abnormality of the left hip joint itself.  Therefore, the Board concluded there was no evidence to support consideration of a separate rating for left hip impairment.  The VA granted a separate rating for pelvic fracture based on right hip pain with motion at the post-separation VA C&P examination.  The Board noted the right pubic bone fractures could cause pain with right hip motion from the attachments of ligaments and tendons to the pubic bone.  However, X-rays demonstrated healing of the fractures with normal alignment and right hip pain was not recorded in physical therapy or orthopedic examinations proximate to separation.  Right hip ROM was normal without pain and gait was normal.  Therefore, the Board concluded there was no evidence to support consideration of a separate rating for right hip impairment due to residuals of the pelvic fracture.  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 pelvic fractures and transverse process fracture of L3 condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determinations regarding the adjustment disorder, sleep disturbance and pulmonary contusion conditions.  The Board’s threshold for countering fitness determinations is the “preponderance of evidence,” which is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Adjustment disorder.  The CI was evaluated in the mental health clinic on 15 December 2006 for difficulty adjusting to military life and keeping up with technical training.  She reported having depressive symptoms since entering basic training with difficulty establishing a social network.  She was experiencing loss of concentration and attention and was having difficulty learning the material in technical training.  Due to failing examinations, she was placed in ineffective status on 5 January 2007 pending evaluation and administrative actions for elimination from training.  A clinic evaluation 19 January 2007 noted the CI was having difficulty adjusting to the military way of life and felt depressed.  The Air Force was much harder than she anticipated; she was having difficulty learning the material, and was flunking out of class.  As noted above, the CI was hit by the truck on 23 January 2007.  Initial medical evaluations from the rehabilitation hospital recorded that there was no loss of consciousness at the time of the accident and the records are silent with regard to complaints referable to a head injury.  The mental health evaluation 6 March 2007 noted some persistent depressive symptoms without thoughts of suicide.  On examination, the mood was characterized as good with normal affect.  Speech was monotone and low in volume but thought processes were normal, coherent, logical, and goal directed.  There was some problem with short term memory noted.  Judgment and insight were deemed adequate.  The examiner diagnosed adjustment disorder with mixed anxiety and depressed mood, acute.  The examiner also noted there was no physical cause for the mental and cognitive symptoms experienced by the CI.  A 26 March 2007 clinic examination noted absence of headaches.  At the time of the 7 November 2007 VA C&P examination, the examiner indicated there was a negative response from the CI regarding the presence of psychological symptoms including depression, anxiety or memory loss.  On mental status examination, mood, affect, memory, speech, and judgment were normal.  The CI developed symptoms consistent with adjustment disorder in response to the routine stressors of basic and technical training.  The post-separation VA C&P examination indicated resolution of symptoms also supporting the diagnosis of adjustment disorder.  Adjustment disorder does not constitute a physical disability, and therefore is not ratable IAW DoDI 1332.38.  Although a VA C&P examination on 31 December 2008 diagnosed PTSD attributed to the January 2007 accident, there was no evidence of symptoms of PTSD at the time of separation.  The CI also reported problems with sleep disturbance and also reported persistent problems with sleep at the VA C&P examination.  However there was no evidence that this problem interfered with performance of duty sufficiently to conclude it was unfitting.  

Pulmonary contusion.  According to treatment records the CI incurred a bruise of the lung (pulmonary contusion) with a small pneumothorax on the right (air leakage into the space between the chest wall and the lung due to injured lung tissue) at the time of the accident.  Medical examinations while in rehabilitation noted absence of shortness of breath.  The MEB narrative summary recorded there was no complaint of chest pain or shortness of breath.  Pulmonary function tests on 8 June 2007 showed a mild degree of restriction (decrease in the total volume); however the forced vital capacity was 80% of predicted, which is considered at the lower end of the normal range.  There was also possible early obstructive impairment indicating a mild degree of small airway disease unrelated to a lung bruise.  The diffusion capacity of the lungs was normal.  A pulmonary consultation on 30 June 2007 noted the history of a pulmonary contusion on the right side and CI report of occasional pain with a deep breath localized to the epigastric region (center of the upper abdomen) and pain in the low back with sneezing.  However there was no chest wall pain.  The physical examination was normal.  The pulmonary specialist noted a CT scan on 29 May 2007 did not show any significant abnormalities.  The pulmonary physician stated “She is not very symptomatic in view of no hemoptysis, no orthopnea and no current shortness of breath.”  At the 6 July 2007 follow-up with pulmonary (4 days after separation) the CI reported shortness of breath with exertion and occasional chest tightness especially with running.  The physical examination was normal and the pulmonary specialist noted the mild restrictive defect and normal diffusion.  The pulmonologist advised no treatment and follow-up in approximately 6 months.  At the VA C&P examination, the CI reported shortness of breath and chest pain with breathing.  She stated she avoided running.  On examination there was tenderness of the lower rib cage on both sides.  The lung examination was normal (auscultation and percussion).  Chest X-ray demonstrated “old” healed fractures of the left seventh and eighth ribs but was otherwise normal (no lung abnormality or pneumothorax).  Although the CI reported problems with shortness of breath following separation, there was no evidence by imaging (CT scan, chest x-ray) or pulmonary function testing of any residual impairment that would be sufficient to consider unfitting for continued military service.

 After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB determination for the any of the contended conditions and so no additional disability ratings are recommended.

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.  In the matter of the pelvic fractures and transverse process fracture of L3 condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder, sleep disturbance, and pulmonary contusion conditions, the Board unanimously recommends no change in the PEB determinations.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization 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

XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00417.

	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,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR