RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE: pd-2014-01531 
BRANCH OF SERVICE:  Army	SEPARATION DATE: 20040229 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Voice Interceptor) medically separated for chronic back and hip pain.  The back and hip conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Chronic right sided low back pain with right hip pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded bilateral shin splints and bilateral tibial stress fractures as meeting retention standards.  The Informal PEB adjudicated “chronic back pain and hip pain” as a single unfitting condition, rated 10%, citing application of 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:  The CI contends the MEB considered only part of her diagnosis and her conditions continue to worsen.  Her complete submission is at Exhibit A.

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 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:  

IPEB – Dated 20031107	VA* - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back and [R] Hip Pain	5099-5003	10%	Sacroiliac Joint Dysfunction	5299-5237	10%	STR	
			Degenerative Joint Disease, Right Hip	5299-5252	10%		
Other MEB/PEB Conditions x 1 (Not In Scope)	Other x 4	
RATING: 10%	COMBINED RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20040428 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  As noted above, the PEB combined two potentially separate conditions under a single Service disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 the Board must apply the same rules if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for Service rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for lumbar spine and right hip conditions are presented separately; with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Lumbar Condition.  The service treatment record (STR) corroborated the history in the narrative summary (NARSUM) of an atraumatic onset of back pain in 2001 (2 years prior to separation).  The condition was managed conservatively and first profiled in October 2002.  Magnetic resonance imaging (MRI) in January 2003 (13 months prior to separation) diagnosed disc disease (anomalous four lumbar vertebrae, “moderate” protrusion at L4/S1 with bilateral neural foraminal narrowing).  There were no radicular symptoms throughout the course with multiple normal neurologic examinations (5/5 strength) in evidence and surgery was not recommended.  A temporary profile for back pain was issued in October 2002, and a protracted trial of continued conservative treatment was unsuccessful.   There were various STR entries documenting grossly normal thoracolumbar range-of-motion (ROM), albeit with painful motion, and none to the contrary.  There was an early physical therapy (PT) entry that noted an antalgic gait that was not clear if attributable to hip, back, or both.  A later PT entry documented a normal gait as an accomplished therapy goal.  There were no subsequent STR entries which documented an abnormal gait, some which documented normal spinal contour (none to the contrary), and there was no STR documentation of incapacitating episodes.   

The NARSUM was conducted 4 August 2003 (7 months prior to separation) and documented “moderate ... frequent” pain prohibiting running or lifting more than 40 pounds.  The symptom acuity and functional limitations were presented in the NARSUM as the combined effect of both conditions.  The NARSUM physical examination was recorded grossly as “within normal limits,” and contemporary ROM measurements from PT were cited.  These were flexion to 90 degrees (normal) and combined ROM of 195 degrees (normal 240).  Mechanical versus pain limitation of ROM was not specified, but painful motion may be reasonably assumed.  Subsequent PT ROM measurements are in evidence from 10 October 2003 (4 months prior to separation) which documented 90 degrees flexion and 235 degrees combined.  The lumbar condition was permanently profiled and the commander’s performance statement did not differentiate functional limitations attributable to specific orthopedic conditions.  

The CI failed to report for a scheduled VA examination and there was no post-separation VA (or civilian) evidence for this case.  

The Board directed attention to its recommendations based on the above evidence.  The Board first considered if the lumbar spine condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting (as above).  It is clear that the functional limitations from both conditions were closely inter-related, but the clinical acuity of each one was significant.  Members judged that the lumbar disc condition more likely than not would have, in itself, significantly interfered with combat load bearing and other general soldiering requirements and it was noted that the back had been separately profiled for over a year preceding separation.  Members thus agreed that a preponderance of evidence supports a conclusion that the lumbar condition was reasonably justified as separately unfitting and accordingly a separate Service rating is recommended. 

Having so concluded, the Board turned to deliberation of the appropriate coding and rating recommendation for the lumbar condition.  Both satisfactory evidence of painful motion and the PT combined ROM support the minimum compensable rating of 10%.  There is no ROM evidence supporting a rating higher than 10%, no evidence for abnormal gait or contour to support a 20% rating and no evidence for ratable peripheral nerve impairment which would provide for additional rating.  No documentation of incapacitating episodes which would provide for a higher rating under that formula was in evidence.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the lumbar spine condition as separately unfitting, coded 5299-5243 (intervertebral disc syndrome) for its clinical compatibility.

Right Hip Condition.  A complaint of right hip pain surfaced at the same time as the back pain (no trauma) and was managed conservatively in concert with the back condition.  It followed a similar unsuccessful trial of conservative treatment, and a temporary profile for right hip pain was issued several months prior to the back profile in July 2002.  Hip X-rays and an MRI were normal, but a bone scan demonstrated inflammation of the right hip noting “mild increased tracer uptake overlying the right acetabulum.”  The STR clinical notes nevertheless reflect an evolution of the working diagnosis from hip joint pain to right “sacroiliitis” or “sacroiliac joint [SIJ] dysfunction.”  However, no SIJ pathology was detected on the lumbar MRI or bone scan.  There are numerous STR entries documenting grossly normal hip ROM, albeit with painful motion, and none to the contrary.  There were no STR entries indicating joint impingement, instability, significant weakness, or other ratable features.

The NARSUM listed “right greater trochanteric bursitis, stable” (although no STR documentation of that diagnosis) under “all other conditions,” and treated the right hip pain as accompanying the back pain.  Thus, the severity, functional evidence, and physical examination as elaborated above were applicable also to the hip component.  The NARSUM cited PT ROM measurements for the right hip as 110 degrees flexion (normal 125, minimum compensable 45) and 20 degrees extension (normal), with an assumption of painful motion as per the lumbar ROM.  The hip pain was permanently profiled as “right sacroiliitis” (parenthetically noted with the back condition).  As above, there was no probative evidence from the commander regarding fitness implications specific to the hip and there was no post-separation evidence.

The Board directed attention to its recommendations based on the above evidence, first considering if the hip (and/or sacroiliac) condition was reasonably justified as separately unfitting.  Members agreed that both clinically (recalling that hip disease was the only positive finding with imaging) and functionally (distinct symptoms apart from back pain), the hip condition was fairly treated as a separate and distinct condition.  As discussed above with the lumbar rating, the fitness limitations are intertwined with the spine disease and members agreed that the fitness conclusions for the hip component were the same as those elaborated above for the spine component.  The hip/SIJ pain would be reasonably expected to separately impede physical operational requirements.  Members thus agreed that the preponderance of evidence reasonably justified the hip (and/or sacroiliac) condition as separately unfitting and subject to separate Service rating.

The Board turned to deliberation of the appropriate coding and rating recommendation.  Members agreed that both VASRD §4.59 (painful motion) and §4.40 (functional loss) were sufficiently evidenced to support the minimum compensable rating of 10%.  There was no compensable ROM limitation under the applicable codes and there was no ankylosis, fracture deformity, flail joint or instability, or nonunion/malunion that would achieve a rating higher than 10% under any alternate code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the right hip/sacroiliac condition as separately unfitting coded 5099-5022 (periostitis) for its clinical and functional compatibility.

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 was operant in this case and it was adjudicated independently of that policy by the Board.  In the matter of the Service combined lumbar/right hip condition, the Board unanimously recommends that it be rated for two separate unfitting conditions as follows:  a lumbar spine condition coded 5299-5243, rated 10%, and a right hip/sacroiliac condition coded 5099-5022, rated 10%; both IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

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

CONDITION	VASRD CODE	RATING	
Intervertebral Disc Disease, Lumbar Spine  	5299-5243	10%	
Arthropathy, Right Hip and Sacroiliac Joint	5099-5022	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140401, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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, AR20160003134 (PD201401531)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA