RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02429
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Healthcare Specialist, medically separated for “sacroiliitis,” with a rating of 10%.  

CI CONTENTION:  The CI requests that Board review all of his conditions.  The CI’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 - 20061208	VARD - 20090116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Sacroiliitis Without Neurologic Deficit	5236	10%	Low Back Strain with L4-L5 Herniated Disc and Sacroiliac Joint Instability	5236-5237	20%	20080612	
			Left Leg Sciatica associated with Low Back Strain with L4-L5 Herniated Disc and Sacroiliac Joint Instability	8620	10%		
Adjustment Disorder with Depressed Mood	Not Unfitting	Chronic Depression (to include Adjustment, Displacement, or Anxiety Disorders)	9434	10%	20080617	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Sacroiliitis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s sacroiliitis condition began in March 2006 after falling down a flight of stairs.  Diagnostic imaging studies of the lumbosacral spine were normal.  
The CI was evaluated by the pain management clinic on 5 September 2006 and reported no change to 9/10 pain which was aggravated by all activities.  He reported that the pain sometimes radiated and worsened during exercise.  The examiner noted tenderness on palpation, decreased flexion and extension and pain on motion.  There was an abnormal forward bend and positive flamingo tests (tests for strength of the leg, pelvic, and trunk muscle as well as dynamic balance).  There was no muscle spasm and straight leg raise testing (for radicular symptoms) was negative.  Motor and strength testing was normal.  The diagnoses were sacroiliitis and muscle spasm, with treatment being narcotic pain medication and muscle relaxants.  Magnetic resonance imaging (MRI) studies of the lumbosacral spine taken on 5 September 2006 were normal.  A bone scan done 7 September 2006 also showed a normal spine.  At the Neurology clinic appointment on 12 September 2006 the examiner noted that the CI presented with “multiple somatic complaints” and that he “continues to have minor traumatic incidents that have incapacitated him.”  The examiner recorded that the CI had had an “extensive evaluation with total spine imaging negative.”  Gait was normal and there was no motor or neurologic abnormalities noted.  The diagnosis was adjustment disorder with resulting somatization.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “sacroiliitis” for PEB adjudication.  

The MEB NARSUM examination on 11 October 2006 (3 months prior to separation) noted complaints of persistent low back pain since his falling accident in March 2006.  It was noted he had “been evaluated through Orthopedics, Neurology and Pain Management Services and no significant findings have been identified as cause for his complaint of pain.”  The CI complained of significant pain and discomfort of his lumbosacral spine and intermittent bouts of numbness in his left lower extremity.  Physical examination showed that the CI arrived to the examination in a wheelchair with a cane for assisting him in ambulation.  He had exquisite tenderness to the left much greater than right sacroiliac joints.  He was non-tender to palpation over the lumbar spinous processes or the paraspinous muscles.  He had a positive Faber’s bilaterally (pain on pelvic/hip motion).  He had negative Waddell’s signs for non-physiologic findings.  Range of motion (ROM) was extremely limited by pain as summarized below.  Motor, reflex and sensory testing were grossly intact in all distributions, except the CI complained of decreased sensory to the plantar aspect of both feet.  

At the VA Compensation and Pension (C&P) examination on 12 June 2008, performed 18 months after separation, the CI reported that he injured his back after a fall in September 2007.  He presented in moderate distress with complaints of back pain.  He was using a cane as an assistive device and had an antalgic gait.  The examiner answered “yes” to the question “Are there abnormalities of spinal muscle, such as guarding, spasm, tenderness, etc?”  The examiner did not elaborate further.  A CT scan on 20 May 2008 showed a tiny disc bulge at L4-L5 without spinal stenosis.  The ROM examinations 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)	NARSUM ~3 Mos. Pre-Sep	VA ~18 Mos. Post-Sep	
Flexion (90 Normal)	25	35	
Combined (240)	120	80	
Comments	Painful motion; tender	Tenderness; no spasm; antalgic gait; cane	
§4.71a Rating	40% (PEB 10%)	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the “sacroiliitis, without neurologic deficit” condition 10% coded 5236 (sacroiliac injury and weakness), citing tenderness and ROM limited by pain.  This was adjudged likely application of AR 635-40 as measured active ROM met the 40% criteria.  The VA rated the low back condition 20% coded 5236-5237 (sacroiliac injury and weakness and lumbosacral strain), based on the VA C&P examination 18 months after separation, citing limitation of forward flexion.  The VA also awarded a 10% rating for left leg sciatica coded 8620 (sciatic nerve, neuritis).  

The PEB rating was likely application of AR 635-40, B-29 (in effect at the time) which stated that ratings for loss of joint motion could only be awarded where a mechanical basis for limited motion is found, and that pain-limited motion did not constitute a basis for rating.  VASRD rating criteria are based on active range of motion and include limitation due to pain.  The VA examination’s probative value was markedly decreased as it was 18 months remote from separation.  The Board adjudged that the NARSUM examination had the highest probative value for rating at separation.  

The Board agreed that a 40% rating, was justified for limitation of flexion not greater than 30 degrees) reported on the MEB NARSUM examination.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The PEB’s disability description was adjudged as indicating their determination that no radiculopathy was unfitting.  The CI reported left lower extremity paresthesia/numbness to the left leg and foot and the NARSUM examination indicated subjective decreased sensory to the bottom of both feet.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The sensory deficit would not have impacted fitness.  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an additional disability rating was not justified on this basis. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the sacroiliitis condition, coded 5236.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the CI’s “adjustment disorder with depressed mood” condition was not unfitting.  The adjustment disorder is a condition not constituting a physical disability, IAW DoDI 1332.38 in effect at the time.  Therefore, the Board has no basis for recommending it as unfitting.  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 contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the sacroiliitis condition, the Board unanimously recommends a disability rating of 40%, coded 5236 IAW VASRD §4.71a.  In the matter of the contended “adjustment disorder with depressed mood” condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Sacroiliitis Without Neurologic Deficit	5236	40%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140424, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

JUL 27 2016

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160010932 (PD201402429)

1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual's separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual's original medical separation for disability with severance pay.

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:

a. Providing a correction to the individual's separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

Enclosure

CF:
( ) DoD PDBR
( ) DVA