RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02646
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Light Wheeled Vehicle Mechanic) medically separated for chronic hip and low back pain.  The condition 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 “sacroiliac joint dysfunction” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “chronic left hip and low back pain” as unfitting, rated 10%, with application of the Veterans’ Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI elaborated no specific contention in her application.  

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 20040311	VA* - (~3 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Hip and Low Back Pain	5237	10%	Sacroiliac Joint Dysfunction/Hip	5236-5237	10%	20040408	
Other x 0 (Not In Scope)	Other x 7 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20041025 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  
  
Left Hip/Sacroiliac Condition.    The service treatment record (STR) corroborates the history in the narrative summary (NARSUM) of an onset of pain in the left hip area in May of 2002, precipitated by ruck marching during advanced individual training.  The initial diagnosis was thigh muscle strain, and it was treated accordingly.  A bone scan soon after onset showed mild bilateral periosteal reactions (bone splints) of the distal femurs, a finding logically unrelated to the chief complaint; and, follow-up bone scans were reported as normal.  The continuing pain was in the area of the left hip and left sacroiliac joint (SIJ), with radiation to the low back by the end of the clinical course.  The working diagnosis starting in August 2003 (10 months pre-separation) was “SIJ dysfunction/low back pain;” an impression corroborated by an orthopedic consultant the following month, who confirmed that there were no surgical indications.  Hip, pelvis and lumbar X-rays were normal; and, there are no directed exams or other ancillary studies focused on the lumbar spine; nor, is there any exam or ancillary evidence specifically implicating hip pathology.  Early STR entries indicated an antalgic gait, but normal gait was documented in all later notes.  There is STR evidence for the absence of lower extremity neurological complaints, and normal neurological testing with 5/5 motor strength of the lower extremities.  There are multiple entries documenting grossly normal range-of-motion (ROM) of the left hip (but painful motion), with no comments regarding lumbar ROM observations.  Formal hip and lumbar ROM measurements for the MEB by physical therapy (PT) were reported as normal in all planes.  There are no STR entries indicating significant functional limitations, gross ROM limitation of the hip or spine, hip joint impingement, neurologic deficits or muscle weakness, or periods of incapacitation.

The NARSUM was conducted 11 February 2004 (5 months pre-separation) and documented constant pain rated 5-6/10 “in her lower back and left posterior gluteal region with occasional radiation to her left lateral hip” with occasional painful ‘popping’ of the hip, interfering with “running, prolonged sitting or standing, and heavy lifting.”  The NARSUM physical examination recorded a normal gait, tenderness confined to the SIJ (specifically noting the absence of lumbar, paraspinal, hip, pelvis, or femur tenderness), a negative test for hip pathology (FABER), 5/5 lower extremity strength, and cited the normal hip and lumbar ROM measurements by PT (above).  The NARSUM diagnosis was “sacroiliac joint dysfunction.”  The commander’s performance statement implicated only profile and general soldiering limitations, noting that walking was unaffected.

A VA Compensation and Pension (C&P) examination was conducted 8 April 2004 (11 weeks pre-separation) and did not elaborate the nature of the pain or specific functional limitations.  The VA physical examination recorded a normal gait, SIJ tenderness only, and normal lower extremity reflexes.  Formal ROM measurements were inadvertently provided for the uninvolved right hip, without left hip measurements; although, it is quite possible that the recorded measurements (all normal) were for the left hip and mislabeled.  Lumbar ROM measurements were flexion to 90 degrees (normal), extension to 15 degrees (normal 30), and right and left lateral flexion to 25 degrees (normal 30); without specifying painful motion or providing rotational measurements necessary for calculation of combined ROM.  The VA examiner documented “overall impression: sacroiliac joint irritation ... minimal amount of physical impairment ... takes no medication;” and, “normal evaluation of the spine ... cannot ascribe any physical impairment to this complaint.”

The Board directed attention to its rating recommendation based on the above evidence; and, members carefully considered the issue that both left hip and thoracolumbar pain and limitations were implicated in this case.  The clinical evolution and preponderance of clinical evidence, however, implicate a dominant diagnosis of left SIJ dysfunction as the only VASRD ratable condition.  This was opined by the MEB orthopedic consultant, NARSUM physician, and the pre-separation VA rating examiner; and, that opinion is supported by the Board’s medical action officer.  Furthermore members agreed that it is not possible to differentiate separate joint and spine ratings in this case without violation of VASRD §4.14 (avoidance of pyramiding).  Even if a single rating with analogous coding under one of the VASRD §4.71a hip codes was substituted to avoid a conflict with §4.71a, no rating greater than 10% is achievable with the ratable findings and functional limitations in evidence; the latter referable to consideration of rating under 5299-5255 (femur, impairment of) for contiguous hip disability.  Sacroiliac joint dysfunction is coded 5236 (as per VA’s hyphenated code) and defaults to rating under the general spine formula, the same criteria applicable to the PEB and VA ratings under 5237 (lumbar strain).  The Service and VA ROM evidence for the spine is consistent with a §4.71a rating of 10% (conceding painful motion). There is no evidence of gait or spinal contour abnormality to achieve a rating higher than 10%, no evidence of additionally ratable peripheral nerve impairment, and no documentation of incapacitating episodes which would provide for a higher rating under that formula.  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 of the left hip/sacroiliac 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 left hip/sacroiliac condition and IAW VASRD §4.71a, 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, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.   

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140604, 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, AR20160003702 (PD201402646)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA