RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02623
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050713

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Light Wheeled Vehicle Mechanic) medically separated for back and hip pain conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  A profile allowed for an alternate aerobic event to satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Chronic low back pain and chronic right hip pain were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated chronic back pain and chronic pain, right hip as unfitting, rated 10% and 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) for the back pain, and citing application of the US Army Physical Disability Agency (USAPDA) pain policy for the right hip condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  The applicant makes no specific contention in his application.  His 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 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 20050328	VA* - (~4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5237	10%	Intervertebral Disc Syndrome with Right Paracentral Disc Bulge and Right-Sided Herniation	5243	20%	20051130	
			Right Lower Extremity Radiculopathy	8525	10%	20051130	
Chronic Pain, Right Hip	5099-5003	0%	Right Hip Bursitis	5019-5253	20%	20051130	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20060214 (most proximate to date of separation [DOS])
ANALYSIS SUMMARY:  

Chronic Back Pain Condition.  The MEB narrative summary (NARSUM) detailed that the CI developed back pain in 2003 (2 years prior to separation) while working on a vehicle.  This progressed into chronic daily pain and “an exertional right lower extremity radiculopathy.”  An electromyelogram revealed electrophysiologic (nerve) evidence of mild right L5 lumbar radiculopathy (generic pathological condition of the nerve roots).  Magnetic resonance scanning showed disc bulges at L4-5 and L5-S1 which narrowed the right foramen (space) and abutted (border on) the exiting right nerve roots.  Neurosurgery was consulted and stated that surgical intervention was unlikely to improve the symptoms.  She was unable to do basic soldiering activities and was referred to the MEB.

At primary care appointments on 1 September and 20 October 2004, approximately 10 months prior to separation, the CI had normal muscle tone and sensation, and normal gait.  The thoracolumbar spine did not demonstrate full range-of-motion (ROM), but did have a normal appearance.  In a memorandum to the PEB a week later, the CI’s commander stated that the CI performed all her duties in satisfactory manner, always ensuring that the mission was successfully accomplished.  Also, “She has proved to me and her supervisors that she is more than capable of accomplishing her tasks.”  A physical therapy evaluation on 29 October 2004 (9 months prior to separation) showed forward flexion of 70 degrees (normal 90) and combined ROM of 205 degrees (normal 240), limited by pain.  The DD Form 2808, Report of Medical Examination, was accomplished on 8 November 2004 (8 months prior to separation) and showed a slight decrease in strength of right foot dorsiflexion, while the “Spine, other musculoskeletal” portion of the examination was reported as “Normal.”  The MEB NARSUM examination was done a week later and showed normal gait and station, with no significant local tenderness of the back.  There was no evidence of muscle atrophy, strength in the upper and lower extremities was normal, and sensation was normal.  A VA neurosurgery note on 17 February 2005 (5 months prior to separation) stated that the CI had normal gait, normal strength of all lower extremity muscle groups, and slight decreased sensation to light touch on the right thigh.

At the VA Compensation and Pension (C&P) General exam on 30 November 2005 (4 months  after separation), the CI noted occasional numbness in the right leg, worse with prolonged standing and sitting.  On examination, she had normal gait, and no deformity or local tenderness of the spine.  At the VA C&P orthopedic exam on the same day, the CI had stable gait.  At the VA C&P Spine exam performed on the same day (same examiner as the orthopedic exam), the CI reported that she “gets numbness in the right lower extremity.”  She reported that she had seen the military doctor several times over the previous year, and “bed rest was advised at least 14 days in the whole year.”  She did not use an assistive device, she could walk about 2 miles in one hour, and her gait was not unsteady.  On examination, forward flexion was 90 degrees and combined ROM was 240.  There was objective evidence of painful motion, and “Range of motion was additionally limited 14 degrees” after repeated movement.  There was no muscle spasm, no weakness, and no fixed deformity; but there was “some sensory deficit” on the right lower extremity L4-S1 innervated area.  At the VA C&P neurological exam on 1 December 2005 (5 months after separation) the CI had normal (5/5) strength “all over,” no atrophy, and normal sensation.  The CI got up and walked slowly, and heel and toe walk were both difficult.  Forward flexion was 55 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB rated the condition at 10%, analogously coded 5237 (Lumbosacral strain), citing no significant neurologic abnormality and combined ROM of 235 degrees.  The VA rated the condition at 20%, coded 5243 (Intervertebral disc syndrome), citing forward flexion to 55 degrees and abnormal gait.  The VA also recommended a rating of 10% for right lower extremity radiculopathy, coded 8525 (Paralysis of posterior tibial nerve).  There was a disparity between the examinations with implications for the Board's rating recommendation.  The Board deliberated the probative value of these conflicting evaluations, and carefully reviewed the entire file for corroborating evidence from the period preceding separation.  VA C&P exams on consecutive days (30 November and 1 December 2005) supported different ratings (10% vs. 20%), based on thoracolumbar forward flexion.  The only other probative examination prior to separation (physical therapy on 29 October 2004) also supported a 10% rating based on ROM.  The VA neurology exam also described abnormal gait, but all other exams described normal or stable gait.  The neurologist did not provide documentation of any re-injury or other aggravation in explanation of the significant increase in symptom severity and worsening physical limitations (including ROM) which contrasted sharply with the previous exams.  Members agreed that full weight could not be given to the subjective elements (severity of symptoms, etc.) of the neurology evaluation in the context of the contradictory history and objective evidence; nor could any medical opinions premised on the conflicting history be weighed as heavily.  Although the CI reported that bed rest was advised at least 14 days in the previous year, this was not documented or supported in the service treatment record.  The Board did not see a pathway to a rating higher than 10% based on ankylosis, ROM, abnormal gait or spinal contour, or physician-prescribed bed rest.  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 chronic back pain condition.

Members considered whether additional rating could be recommended under a peripheral nerve code, as conferred by the VA, for the associated posterior tibial nerve radiculopathy at separation.  The Board’s threshold for such recommendations exceeds the VASRD reasonable doubt standard for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  The sensory component in this case had no significant functional implications.  Although the DD Form 2808 did report slight decreased strength of right foot dorsiflexion, this was not supported by any other examination, and could not be linked to significant functional consequence.  There is thus no evidence of a separately ratable functional impairment (with fitness implications) from the residual radiculopathy; and, Board members agreed that a recommendation for additional rating could not be supported on this basis.

Chronic Right Hip Pain Condition.  The MEB NARSUM detailed that the CI began complaining of hip pain in 2004.  She felt that her hip popped a lot when she ran and “she [had] pain into her groin.”  She had not been in sick call, no X-rays, or any significant workup for the problem.  She had modified her lifestyle due to her back problem so that she did not run much and therefore did not aggravate the hip as much.  At a primary care visit on 5 October 2004, strength was normal (5/5) and equal, and sensori-motor functions were normal in the extremities.  On 20 October 2004, 2 weeks later, gait and stance were normal, muscle tone was normal, and “No asymmetrical musculoskeletal abnormality was seen.”  Hip ROMs done by physical therapy on 29 October 2004 (9 months prior to separation) were flexion 100 degrees (normal 125), extension 10 degrees (compensable if limited to 5), abduction 30 degrees (normal 45), adduction 20 degrees, and external rotation 30 degrees.

At the DD Form 2808 examination on 8 November 2004 (8 months prior to separation), the CI had decreased ROM of the hip.  At the MEB NARSUM examination a week later, the CI had normal gait and station, no muscle atrophy, and normal strength and sensation.  At a primary care visit 2 weeks later (22 November 2004), the CI had normal gait, hip motion was normal, and a piriformis test of the hips (testing for impact of the piriformis muscle on the sciatic nerve) was negative.  At a neurosurgery evaluation on 17 February 2005 (5 months prior to separation) the CI had normal gait, normal strength of the lower extremities, and decreased sensation to light touch of the right thigh.

At the VA C&P general exam on 30 November 2005 (4 months prior to separation), the examiner described back and knee conditions, but did not mention any hip issues.  At the VA spine exam on the same day, the CI’s gait was not unsteady.  At the joint exam (also same day), the CI complained of pain with walking or bending.  Gait was “stable” and there was tenderness on the anterior aspect of the right hip area.  Hip flexion was 100 degrees with end pain, adduction 20 degrees, abduction 30 degrees, external rotation 60 degrees, and “Extension did not try.”  The examiner added, “The joint range of motion on five repeated use is pain increase to 6 on the scale of 1-10.  Range-of-motion limited additionally 18 degrees.”  

The Board noted that the initial ROMs of the service physical therapy and the VA C&P joint exams were relatively consistent, and supported a rating of 10%.  The VA exam additionally described that the ROM was “limited additionally 18 degrees” after “five repeated use,” without specifically identifying the affected plane or planes of motion.  However, Board members found these latter values to be of limited probative value because the specific planes of movement were not described, it would be unusual for the ROM to be limited by the same amount in all planes after repetitive use, and it was not clear how this applied to hip extension (initially “did not try”).  The same examiner also found thoracolumbar spine ROM “additionally limited 14 degrees” after repeated movement, without mentioning the specific planes involved.  Applying this additional loss of ROM to the original hip abduction (30 degrees) would result in 12 degrees, and a higher rating of 20% would be indicated only if abduction was lost beyond 10 degrees.  Considering that “no asymmetrical musculoskeletal abnormality was seen” and “hip motion was normal” at two primary care exams, and gait and strength of the hip was consistently normal, Board consensus was that the preponderance of evidence supported a rating of 10% under code 5253.  A higher rating was not supported under any other hip and thigh code, or under code 5003 (degenerative arthritis).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommended a disability rating of 10% for the chronic right hip pain 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating right hip pain was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right hip pain condition, the Board majority recommends a disability rating of 10%, coded 5253 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	
Chronic Back Pain	5299-5237	10%	
Chronic Pain, Right Hip	5253	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140530, w/atchs
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 XXXXXXXXXX, AR20160003422 (PD201402623)

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