RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01849
BRANCH OF SERVICE:  Army	BOARD DATE:  20150505
SEPARATION DATE:  20061215

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 right hip and chronic low back pain (LBP).  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The right hip and chronic LBP conditions characterized as “right femoral neck stress fracture” and “spondylolysis of L5-S1,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were forwarded for adjudication.  The Informal PEB adjudicated “fracture of the femoral neck of the right hip” and “chronic low back pain,” as unfitting, rated 0% each, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “VA rating is higher than DoD.”

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:

IPEB – Dated 20061206	VA* - (~5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Hip Pain	5299-5255	0%	Residuals Of Right Femoral Neck Stress Fracture	5255	0%	20070507	
Low Back Pain	5299-5237	0%	Spondylolisthesis, L5-S1	5239	10%	20070507	
Other x 0 (Not In Scope)	Other x 3	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070524 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Hip Pain Condition.  The CI’s right hip pain began during basic training and was diagnosed as a stress fracture of the right femoral neck in July 2006.  The CI was sent to the physical therapy rehabilitation program in August 2006 where she remained for several weeks.  She was placed on a weight bearing limitation protocol and progress had been slow.  As she increased her activities in the therapy program, she began to report increasing LBP.  The narrative summary (NARSUM) dated 1 November 2006, 6 weeks prior to separation, recorded that both hips had full range-of-motion (ROM) and were non-tender on manipulation during ROM testing.  All muscle groups of the lower extremity were normal in strength, and sensory function was intact.  The physician opined that because the CI suffered from two chronic pain issues and was still in basic training, the physical demands of basic training would likely continue to exacerbate her pain and therefore, she should be medically separated.  At the VA Compensation and Pension (C&P) examination, approximately 5 months after separation, the CI indicated she has recurring pain in the right hip region with activity such as crossing her legs.  Resting reduces the pain and the condition had minimal effects on her day-to-day activities.  Physical examination of the right hip revealed ROM flexion of 125 degrees (NL=125), extension of 0 degree, and abduction of 38 degrees (45), there was no evidence of pain on motion in all parameters, nor additional loss of motion on repetition.  Additionally, there was no evidence of neuromuscular or vascular compromise.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the condition at 0%, coded analogously 5299- 5255 (impairment of femur), noting although the examination of the hip was normal, the CI could not perform the duties of her MOS or of a Soldier.  Likewise the VA assigned a 0% disability rating, noting that without evidence of a malunion of the femur with slight knee or hip disability or ratable limitation of motion, the condition was not compensable.  The Board noted ROM recorded by physical therapy (undated) that demonstrate, full right hip flexion on three trials with average of 133 degrees (N=125), and extension averaging 21 degrees (N=20).  After a careful review of all codes related to the hip (5252, 5251, and 5253) the Board found no pathway to a higher rating for the hip condition.  The Board also concluded the applications of VASRD §4.40 and § 4.59 were not applicable in this case.  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 fracture of the femoral neck of the right hip condition.

Low Back Pain Condition.  The NARSUM noted the back pain was insidious in onset without history of trauma, and began after the CI’s hip pain condition.  Radiographs of the lumbar spine revealed an L5-S1 spondylolysis without spondylolisthesis (one bone slides over the one below it), and no significant step off (abnormal space between vertebrae) was noted between the levels of L5-S1; however, the examiner indicated there was a small step off that was opined to be a pre-existing anomaly that may have been exacerbated by the increased activity associated with basic training.  Physical examination of the spine revealed slight tenderness on deep palpation, and “full” ROM without tenderness on motion.  Muscle strength, neurovascular examination, and sensation were all normal.  Physical therapy undated entry recorded thoracolumbar ROM flexion on average of three, 135 (N=90), and extension averaging 28 (N=35).  At the VA C&P examination, approximately 5 months after separation, lumbosacral ROM measurements recorded flexion of 90 degrees, and extension of 30, without evidence of pain on motion, and no additional loss of motion on repetition.  Radiographs taken at the VA demonstrated slight displacement of L5-S1, opined to be a pars defect, and diagnosed as spondylolisthesis of L5 on S1.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition 0%, under the analogous code 5299-5237, and cited, “Radiographic studies documented complete L5-S1 spondylolysis without evidence of spondylolisthesis.”  The VA rated at 10% coded 5239 for the condition assessed as spondylolisthesis, L5-S1.  A higher code of 20% which requires spasms producing abnormal gait, or abnormal curvature of the spine, or forward flexion not greater than 60 degrees, was not supported by the evidence in record.  All Board members agreed there was insufficient evidence to support a rating based on pain-on-motion, or ROM, since painful motion was absent in both NARSUM and VA examinations, and ROM measurements were considered normal.  The Board next considered a rating for the condition of spondylolisthesis which was recorded by the NARSUM examiner as not present on X-ray; however, the NARSUM examiner suggested that there was perhaps a small degree of spondylolisthesis when he stated “there was no significant step off noted between levels L5-S1.”  However, the examiner also stated, “From the appearance of the X-ray, it is unlikely to be an acute pars fracture and more likely to be a pre-existing congenital anomaly that may have been exacerbated by the increased physical activity that came along with basic training.”  The Board acknowledged that there had not been a definitive diagnosis of spondylolisthesis while in service, and radiographs were not among the evidence in the service treatment record.  However, the NARSUM examiner acknowledged some degree of abnormality in the lumbosacral spine, and taken together with the evidence presented at the VA which included radiographic evidence of normal disc spaces, but slight displacement of the body of L5-S1, consistent with the diagnosis of a Grade I spondylolisthesis; all Board members agreed that the back pain condition was compensable under the 5239 code.  As noted above, there was no evidence to support any other coding option. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10%, coded 5239 for the LBP 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 fracture of the femoral neck of the right hip condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic LBP condition, the Board unanimously recommends a disability rating of 10%, coded 5239 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	
Right Hip Condition	5299-5255	0%	
Chronic Low Back Pain	5239	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140415, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXX, AR20150013658 (PD201401849)

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,   I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization 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:

Encl			XXXXXXXXXXXXXXX
				Deputy Assistant Secretary of the Army
				    (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA