RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00568
BRANCH OF SERVICE:  Army	BOARD DATE:  20141204
SEPARATION DATE:  20070518

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (27D20/Paralegal Specialist) medically separated for left hip and low back pain (LBP).  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  An alternate walk, swim or bike fitness test was authorized on her profile.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The left hip and low back conditions, characterized as “chronic left pelvis pain/hip pain” and “lower back pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded an anxiety condition as medically acceptable.  The Informal PEB adjudicated “chronic left hip pain” and “chronic low back pain,” rated at 10% and 0%, referencing the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “It was recognized at the time of my separation that I had degenerative disc disease, and it was remanded to my RO in my Board decision dated 09/12/2012. To date, nothing further has been communicated regarding any action or a decision by the RO. It should be noted that I had continued back pain through my service, which is substantiated in visits to Troop Medical Clinics throughout my enlistment.  I was not aware of the Degenerative Disc Disease (DDD) finding in my imaging until I began preparation for my Board hearing with a very detailed review of the total of my medical records.  It was never communicated to me that I have DDD.  This I believe may be contributing to all of my pain (hip and sciatica), both of which I experienced during my enlistment.  Upon receipt of the notice that I was eligible for a PDBR review, I was unclear on how to get another review of my entire rating.  This process has been fragmented and is at best, confusing.  It seems my 2 subsequent moves out of the state of Tennessee (where I resided when separated) have increased this confusion, but I have done all I can to keep the VA aware of my location.”

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 ratings for the unfitting left hip and low back conditions are 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.

RATING COMPARISON:

Service IPEB – Dated 20070430	VA - (3 Mos. Pre -Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lt Hip Pain	5099-5003	10%	S/P Left Hip Fracture	5299-5253	0%	20070207	
Chronic Low Back Pain	5237	0%	DDD, Lumbar Spine	5242	0%	20070207	
Other x 0 (Not In Scope)	Combined:  0%	
Combined:  10%		
Derived from VA Rating Decision (VARD) dated 20070718 (most proximate to date of separation)
Rating for the left hip condition was changed to 10% in a 20091009 VARD with an effective date of 20070519

ANALYSIS SUMMARY:

Left Hip Condition.  The narrative summary (NARSUM) notes the CI to develop pain in her left hip of uncertain cause during basic training.  A nuclear bone scan performed on 13 November 2003, revealed a healing stress fracture of the left hip inferior pubic ramus (sitting bone of hip).  Despite treatment, pain in the left hip area continued often extending to the left iliac crest (hip crest).  Routine X-rays and a magnetic resonance imaging (MRI) of the hip and pelvis in August 2004 were normal.  Repeat routine hip X-rays and bone scan performed in July 2006 showed no evidence of fracture.

At the VA Compensation and Pension (C&P) exam performed on 7 February 2007, (3 months prior to separation), the CI reported flare-ups of her hip pain twice weekly.  On physical examination the gait was normal.  All joints had full range-of-motion (ROM) and normal motor strength and normal sensory exam.  Further details of this exam are provided in the chart below.  At the MEB NARSUM evaluation performed on 2 April 2007 (2 months prior to separation), exam, the CI reported continued hip pain with running, jumping and prolonged walking.  The MEB physical exam findings are provided below. 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.

Left Hip (Thigh) ROM
(Degrees)	VA C&P ~ 3 Mo. Pre-Sep
(20070207)	MEB (PT) ~ 1 1/2 Mo. Pre-Sep
(20070302) 	
Flexion (125 Normal)	125	96	
Extension (20)	#	5	
External Rotation (45)	45	#	
Abduction (0-45)	40	30	
Adduction (45)	#	#	
Comment	No tenderness to palpation.  Pain with repetition	Painful motion; no spasm	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the hip condition 10% code 5099-5003 (analogous to arthritis) for painful ROM, citing the USAPDA policy on rating pain.  The VA rated the hip condition 0%, code 5253 (thigh impairment), citing normal ROM and that the “subjective complaints of pain on repetition do not meet criteria necessary for compensation.”  The Board unanimously agreed that the hip condition rose to the level of 10% for painful motion IAW §4.40 and §4.59 as supported by the records referenced above.  The Board unanimously agreed that the record did not support a compensable rating under ROM criteria.  The Board agreed that the hip condition was “mild” and rose to rating no higher than 10% under code 5255, which requires “moderate” disability for a 20% rating.  The Board found no other appropriate codes for rating consideration and no pathway to a higher than 10% rating for the hip condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the hip condition.

Low Back Pain Condition.  The NARSUM notes the CI developed LBP without specific injury in November 2004.  An MRI of the lumbar spine on 15 August 2006, revealed slight disc degeneration in the low back without disc herniation or spinal nerve compression.  Despite treatment, the back pain continued without leg weakness or pain radiation.  On a physical medicine evaluation performed on 26 September 2006, the CI had a normal gait and ROM of the spine without pain or spasm.  On chiropractic consultation to the MEB dated 26 October 2006, the gait was recorded as normal; ROM of the spine was “full,” “free of pain” with a normal neurologic examination.  At a chiropractic evaluation on 14 November 2006, ROM was normal but with tenderness to palpation and muscle spasms in the lower back.  At the VA C&P exam performed on 7 February 2007 (3 months prior to separation), the CI reported flare-ups of her back pain 1-2 times a month.  On physical examination the gait was normal.  Exam of the back revealed no tenderness or spasm; motor, sensory and reflex exams were normal.  The examiner reported the CI did report pain during repetitive motion and opined “although the veteran did complain of pain, there is no change in ROM with repetition.  Therefore, I would need to resort to speculation in order to assess any loss of function due to this pain.”  Further findings on this exam are contained in the chart below.  At the MEB exam, the CI made no report of weakness, numbness or pain in her legs.  The MEB physical exam documented normal spinal contour and gait.  There was no pain with motion, no spasm, no guarding and no localized spinal tenderness.  Further findings from this exam are contained below. 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)	VA C&P ~3 Mo. Pre-Sep
(20070216) p.57	MEB(PT)~ 2 Mo. Pre-Sep
(20070313) p.50	
Flexion (90 Normal)	90	90	
Extension (30)	30	30	
Combined (240)	240	n/a	
Comment	No spasms/tenderness/ normal motor/sensory. No crepitation; Pain with repetition	No pain, no localized tenderness, no spasm, no guarding.	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the back pain condition 0%, using different codes; the PEB rated under code 5237 (lumbosacral strain) and the.VA rated under code 5242 (arthritis of the spine).  A higher rating of 10% under either code requires forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees.  The Board unanimously agreed that the evidence in record, referenced above, did not support a compensable rating for the back condition under VASRD ROM criteria.  The Board considered a rating for pain IAW §4.59.  The Board noted the report of pain on motion on the VA exam but none on the MEB exam.  The Board agreed that the absence of spasm, crepitation and tenderness to palpation, the normal gait and carriage, and normal ROM in all directions without reduction on repetition in the VA exam were inconsistent with the presence of significant painful motion.  The Board, thus, gave higher probative to the MEB evaluation in its consideration.  The Board unanimously agreed the findings of this exam do not support a rating for painful motion.  The Board considered a rating under code 5243 (incapacitating episodes/intervertebral disc syndrome).  An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed and treated by a physician.  The record documents no incapacitation under this definition in the 12-month period prior to the MEB examination.  The Board agreed that no rating could be recommended under this code.  The Board considered a rating IAW §4.123 (neuritis, peripheral nerve).  The Board agreed there was no evidence for ratable peripheral nerve impairment in this case, since no motor weakness and sensory symptoms had no functional implication.  The Board found no other appropriate codes for consideration.  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 of 0% for the back 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. As discussed above, PEB reliance on the USAPDA pain policy for rating the left hip was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the left hip condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the back pain condition, the Board unanimously recommends a rating of 0%, coded 5237, IAW VASRD §4.71a.  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 20140102, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX AR20150007092 (PD201400568)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA