RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-01452
BRANCH OF SERVICE:  Army 	      separation DATE:  20090731

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-4, Unit Supply Specialist, medically separated for “low back pain in a setting of spinal stenosis, sacroiliitis, spondylolithesis and degenerative disk disease” [sic] and “left hip pain due to sacroiliitis,” rated 10% and 10% respectively, for a combined disability of 20%.

CI CONTENTION:  The applicant makes no specific contention in their application.  The applicant’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 Veterans Affairs Schedule for Rating Disabilities (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 PEB -  20090615	VARD - 20091003	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain…	5238	10%	Spinal Stenosis…	5010-5237	10%	20090814	
Left Hip Pain…	5099-5003	10%	Left Hip Pain due to Sacroiliitis	5251	10%	20090814	
RATING:  20%	RATING:  20%	

ANALYSIS SUMMARY:  

Low Back Pain (LBP).  The CI was first seen for LBP on 5 January 2007, during his last month of AIT [advanced infantry training].  He reported that he had awoken with it on 8 November 2006 and denied antecedent trauma.  His range-of-motion (ROM), gait, and neurological examination were normal.  He was treated with medications and referred to physical therapy (PT) where his examination remained normal including the ROM.  He was able to complete training.  He was next evaluated on 25 July 2008 and reported ongoing LBP.  Again, his examination was normal including ROM and he was treated with medications.  An X-ray showed degenerative changes.  In PT on 6 October 2008, he noted a 4-5 year history of LBP aggravated by activity.  The ROM was reduced to 75% of normal in all planes.  He was issued a L2 profile restricting sit-ups.  However, it was again normal on 22 October 2008 in a primary care evaluation.  In orthopedics on 29 October 2008, flexion was reduced to 50 degrees and extension to 20 degrees.  The neurological examination was normal.  An imaging test on 5 December 2008 showed multi-level spinal stenosis and degenerative disc disease.  In primary care on 10 March 2009, the ROM was restricted, but not quantified.  The neurological examination and gait remained normal.  He was evaluated in neurosurgery on 16 April 2009 and noted to have a normal neurological examination and signs of inflammation of the left sacroiliac joint (the joints between the spine and pelvis).  The narrative summary (NARSUM) was dated 4 June 2009, 2 months prior to separation.  The CI reported LBP and pain radiating to the left hip.  Despite medications and PT, he had not been able to return to full duty.  On examination, he had a normal gait and stance and could get on and off the examination table without difficulty.  However, he had some discomfort undressing.  Motion was painful and limited as documented below.  Guarding and spasm were absent.  The neurological examination was normal. 

 At the VA Compensation and Pension (C&P) examination performed on 14 August 2009, a month after separation, the CI reported that his LBP began in September 2007 while deployed.  He reported three episodes of incapacitation lasting 36-48 hours.  On examination, there was no tenderness or spasm.  Motion was painful and limited.  The neurological examination and gait were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the back at 10%, coded 5238 (spinal stenosis) and 5010-5237 (traumatic arthritis – lumbosacral strain), respectively.  The Board noted that the 5238 code provided the best clinical description of these, but none of these or any other available code provided a rating advantage.  A 10% rating is supported by the ROM and by painful motion.  While the orthopedist recorded a 50 degree flexion measurement, this was an outlier from all other measurements.  The Board found no route to a rating higher than 10%.  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 fitness determination for the back condition.  

Left Hip Pain.  The CI was found to have left sacroiliitis while in the Medical Evaluation Board (MEB) process.  The NARSUM examiner recorded limitation in motion, but the left side actually exceeded the ROM of the unaffected right side.  Painful motion was not documented.  The CI could out-toe over 15 degrees and cross his legs.  His gait was normal.  At the VA C&P examination, the CI reported that the condition did not affect his occupation or the activities of daily living.  Motion was limited and painful.  His gait was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the left hip condition at 10%, coded, respectively, 5099-5003 (analogous to degenerative arthritis) and 5251 (limitation in extension).  The ROM limitation was not compensable.  The CI reported painful motion on the VA examination but not at the NARSUM evaluation.  The Board found no route to a rating higher than the 10% adjudicated by the PEB.  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 fitness determination for the left hip pain condition.  

BOARD FINDINGS:  In the matter of the low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the low left hip pain due to sacroiliitis 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.   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 20140224, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

26 AUG 2016

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 XXXXXXXXXXXXXXXXXXXX, AR20160006071 (PD201401452)

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:
 						         
Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA