RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-02501
BRANCH OF SERVICE:  Army	BOARD DATE:  20140813
SEPARATION DATE:  20041213

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92Y10/Supply Specialist) medically separated for low back pain (LBP).  The LBP condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The LBP condition, characterized as “chronic musculoskeletal back pain”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  Also identified and forwarded by the MEB were “bilateral snapping hip syndrome” and “right plantar fasciitis” designated as medically unacceptable.  The Informal PEB adjudicated “LBP with full range of motion and no neurological deficits. Soldier also has hip pain. Soldier is tender in the sacroiliac joints” as unfitting, rated 10%.  The remaining condition was determined to exist prior to service and was considered not compensable.  The CI made no appeals and was medically separated.

CI CONTENTION:  “All conditions”

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 rating for the unfitting LBP and hip conditions is addressed below; along with the right plantar fasciitis.  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 20040823	VA - (1 Mo. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain and Hip Pain	5237	10%	Chronic Musculoskeletal Back Pain	5237	0%	20041104	
			Rt Hip Condition	5255	NSC	20041104	
Rt Plantar Fasciitis EPTS	5299-5278	--%	Rt Plantar Fasciitis	5299-5278	NSC	20041104	
Other x 0 (Not in Scope)	Other x 8 (Not in Scope)	20041104	
Combined:  10%	Combined:  0%	
Derived from VA Rating Decision (VARD) dated 20050106 (most proximate to date of separation [DOS]).
VARD dated 20060712 (~18 mos. post-sep) granted 10% for LBP effective 20041214.

ANALYSIS SUMMARY:  The PEB combined the low back pain and hip pain together and adjudicated a single rating.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  Since the PEB did not specifically indicate whether it combined the conditions based on the provision of DoDI 1332.38 for overall effect, the Board will consider each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the Disability Evaluation System or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

Low Back Condition.  Complaints of LBP appeared in the service treatment record (STR) following a fall while deployed in December 2003.  At the time of the Post-Deployment Health Assessment completed by the CI on 7 January 2004, the CI checked back pain on a symptoms list, but reported hip pain as a current health concern.  Orthopedic evaluations on 23 February and 4 March 2004 recorded continued LBP since the fall with complaints of pain radiating into the right leg.  On examination gait was normal and back range-of-motion (ROM) was normal.  Straight leg raising was negative for radicular signs.  Electrodiagnostic testing on 4 March 2004, was normal showing no evidence of a pinched nerve in the back or legs.  X-rays of the lumbosacral spine on 16 March 2004 were normal.  Magnetic resonance imaging (MRI) of the lumbar spine on 19 March 2004, demonstrated a mild bulging L4-5 disc with a possible associated annular tear but without herniation of the disc or compression of neural structures.  A duty limiting profile was issued on 1 June 2004.  The VA Compensation and Pension (C&P) examination on 4 November 2004, a month prior to separation, noted complaint of LBP.  Examination of the back was reported as normal and the examiner stated he could not ascribe any physical diagnosis or attribute any physical impairment to the LBP complaint.  The Board first considered whether the back pain condition was unfitting when considered separately from the hip pain condition.  Although the back and hip pain were somewhat intermingled in treatment records, orthopedic examiners described back pain separately from hip pain and indicated some impairment due to back pain.  The Board concluded that there was not a preponderance of evidence to overcome the PEB’s determination that back pain was the primary unfitting condition.  The Board next considered is rating recommendation for the back pain condition.  The PEB rated the back pain condition (with hip pain) 10% coded 5237 for lumbosacral strain.  The VA initially rated the back pain condition 0% (also coded 5237) but later increased the rating to 10% based on a VA C&P examination from 18 May 2006 (performed 17 months after separation).  The 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)	Ortho ~10 Mo. 
Pre-Sep
 (20040223)	PT ~6 Mo. Pre-Sep
(20040607)	MEB ~ 5 Mo. Pre-Sep
(20040719)	VA C&P ~ 1 Mo. Pre-Sep
(20041104)	
Flexion (90 Normal)	Full ROM	85 (85, 85, 90)	85 (85, 87, 86)	90 (95)	
Extension (30)	Full ROM	30 (30, 35, 30)	20 (17, 18, 20)	15	
R Lat Flexion (30)	Full ROM	30 (40, 45, 40)	30 (36, 34, 35)	25	
L Lat Flexion (30)	Full ROM	30 (50, 45, 50)	30 (35, 36, 35)	25	
R Rotation (30)	Full ROM	30 (40, 45, 45)	30 (40, 38, 37)	30	
L Rotation (30)	Full ROM	30 (45, 50, 45)	30 (38, 39, 38)	30	
Combined (240)	--	235	225	215	
Comment	Pain with extension and left lateral bending
Gait normal.
Leg raising negative	
--	Gait normal.
Pain with flexion to 90.
 	No change after repetition.
Straight leg raise negative.
“normal evaluation”
Gait normal.	
§4.71a Rating	10%	10%	10%	10%	

The mild limitation of motion and tenderness documented in the MEB examinations supports a 10% rating under the VA Schedule for Rating Disabilities (VASRD) general rating formula for diseases and injuries of the spine.  There was no muscle spasm causing altered gait or spinal contour to support consideration for a 20% rating.  Although the MRI demonstrated a bulging disc, there were no incapacitating episodes requiring bed rest prescribed by a physician that supported consideration a higher rating under the alternate formula for rating intervertebral disc syndrome.  There was no associated radiculopathy for separate peripheral nerve rating.  Although there was complaint of radiating pain, there was no objective evidence of a radiculopathy by imaging or electrodiagnostic testing and no objective neurologic deficits.  While the CI may have experienced radiating pain associated with the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There is no evidence in this case that there was radiculopathy with associated functional impairments separately functionally impairing.  The Board therefore concludes that 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 separate unfitting disability rating of 10% for the LBP condition.

Hip Condition.  The CI developed right hip pain during training in February 2002.  She improved and was able to pass the PT test including the run in August 2002 however hip pain recurred several months later and the CI complained of bilateral, right more than left, hip pain with activity.  X-rays, and nuclear bone scanning of the hips were normal.  Orthopedic evaluation diagnosed snapping hip syndrome, a condition where a hip tendon snaps as it moves across a bony prominence of the hip bone and can be associated with bursitis or tendonitis.  Orthopedic examination on 20 May 2003 recorded complaint of right greater than left hip pain.  On examination, gait was normal, and hip ROM was normal bilaterally.  An MRI performed on 2 June 2003 of both hips was normal and showed no evidence of bursitis (fluid collection) or changes suggesting of soft tissue inflammation (such as tendonitis).  The CI was deployed to Afghanistan arriving early August 2003.  While deployed she sought care for her hip pain and requested profiles for duty limitation.  Examinations were similar to prior exams documented in the treatment record.  The CI noted bilateral hip pain as a health concern on the Post-Deployment Health Assessment in January 2004.  Repeat MRI of both hips on 28 January 2004 was again normal and showed no evidence bursal effusion (fluid collection) or soft tissue inflammation.  Orthopedic examination on 23 February 2004, recorded right greater than left hip pain.  Examination noted right hip pain with provocative testing but none on the left.  No hip popping or snapping was detected on this examination.  Evaluation at a civilian orthopedic clinic (by a physical medicine and rehabilitation physician who performed electrodiagnostic testing), noted complaint of right hip pain and “minimal, if any left-sided symptoms.”  On examination, gait was normal.  There was tenderness about the right hip with and intermittent click.  ROM was full.  On 19 April 2004 orthopedic appointment again noted right greater than left hip pain.  The MEB narrative summary (NARSUM) examination on 22 July 2004, recorded a normal gait and normal hip ROM.  At the time of the VA C&P examination on 4 November 2004, a month prior to separation, the examiner recorded complaint of “right hip pain intermittently;” “occasionally gets a snap when she is doing sit ups in her right hip;” and “right groin pain intermittently related to hip pain - now quiescent.”  No complaint of left hip pain was recorded at this examination.  On examination the gait was normal and right hip ROM was normal without snapping.  There were no changes after repetition.  The examiner stated the examination of the right hip was normal and that he could not “…ascribe any physical diagnosis nor attribute and physical impairment to this complaint.”  Subsequent VA examinations are silent with regard to hip pain.  The Board first considered whether the right hip pain and left hip pain conditions were unfitting when each was considered alone, separate from the back and the opposite hip.  The Board noted that right hip predominated throughout the STR and agreed that the right hip pain, when considered separately was unfitting for continued military service.  However the Board concluded the preponderance of evidence did not support a separately unfit determination for the left hip pain condition.  Following return from deployment, right hip pain, not left hip pain, predominated and left sided symptoms were described as minimal if any.  Examinations of the left hip were normal.  The pre-separation VA C&P examination was silent with regard to left hip pain.  The Board concluded that the left hip pain condition could not be recommended for separately unfit disability rating.  The Board next considered is rating recommendation for the right hip pain condition.  The VA concluded there was no evidence of a hip impairment at the time of the VA C&P examination proximate to separation and did not grant a rating.  There was no limitation of hip motion that supported a minimum rating under VASRD diagnostic codes for limitation of motion (5250, 5251, 5252, 5253) and no fracture or malunion of the femur to support consideration under 5255, impairment of the femur.  The Board concluded there was significant improvement by the time of separation such that a 0% rating is appropriate.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the right hip pain condition (coded 5099-5024).

Right Plantar Fasciitis Condition.  The PEB determined the right plantar fasciitis in the setting of pes cavus condition to be unfitting but to have existed prior to service and was not permanently aggravated by service beyond the natural progression of the condition and therefore non-compensable.  The enlistment examination on 6 August 2001, documented pes cavus (high arch).  Following entry on active duty, the STRs were silent with regard to complaints or treatment of plantar fasciitis through the CI’s deployment.  The Post-Deployment Health Assessment was silent with regard to complaints of foot pain.  Orthopedic examination on 23 February 2004 recorded back pain radiating to the medial right foot.  On examination, gait was normal.  At the time of the MEB history and physical examination on 10 June 2004, when the CI reported her right foot began hurting while deployed to Afghanistan.  On examination there was pes cavus and tenderness of the right arch.  The MEB examiner diagnosed right plantar fasciitis.  The MEB NARSUM on 22 July 2004 noted the complaint of foot pain without any further detail.  On examination, the gait was normal and mild tenderness was noted.  Right plantar fasciitis was in the list of diagnoses.  No specific treatment was evidenced in the treatment records.  At the time of the VA C&P examination, right foot pain had resolved with the use of better athletic shoes.  The Board noted minimal documentation of right foot pain in the STRs and the fact that the pain had resolved by the time of the pre-separation VA C&P examination.  The CI had pes cavus documented at the time of entrance into military service, a condition that can predispose to plantar fasciitis.  STRs did not demonstrate treatment or duty restrictions due to the condition suggesting the condition was mild.  By the time of separation, the foot pain had resolved consistent with the PEB’s determination that the pre-existing pes cavus was not permanently aggravated by service.  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 adjudication for the right plantar fasciitis condition and so no additional disability rating is recommended.

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.  In the matter of the LBP condition, the Board unanimously recommends a separately unfitting disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the right hip pain condition, the Board unanimously recommends a separately unfitting disability rating of 0% coded 5099-5024 IAW VASRD §4.71a.  In the matter of the left hip pain condition, the Board unanimously agrees that it cannot recommend it for a separate unfit determination for disability rating.  In the matter of the right plantar fasciitis condition, the Board unanimously recommends no change in the PEB adjudication.  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:

UNFITTING CONDITION	VASRD CODE	RATING	
Low Back Pain 	5237	10%	
Right Hip Pain	5099-5024	0%	
Left Hip Pain	Not unfit	N/A	
Right Plantar Fasciitis; EPTS Without Permanent Service Aggravation	5299-5278	--%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140523, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX, AR20150006381 (PD201402501)

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						     XXXXXXXXXXXXXXXXX