RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03369
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20070912

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E1, Infantry, medically separated for “chronic low back and hip pain, which was diagnosed by rheumatology as ankylosing spondylitis,” with a  disability rating of 10%.

CI CONTENTION:  Please consider all conditions found unfitting by the physical evaluation board.

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 – 20070718	VASRD - 20080122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back And Hip Pain …Ankylosing Spondylitis	
5240	10%	AS of the Sacroiliac Joints	5240-5002	20%	20080122	
			Left Hip OA	5099-5003	10%	20080122	
			Right Hip OA	5099-5003	10%	20080122	
Other x 0 (Not In Scope)	Other x 5	
COMBINED RATING:  10%	COMPLETE COMBINED VA RATING:  50%	

ANALYSIS SUMMARY:  

Chronic Low Back and Hip Pain Diagnosed as Ankylosing Spondylitis.  The CI was first seen for intermittent hip pain in September 2004 and stated that it had been present intermittently since basic training.  He was treated with medications and a profile.  The record then falls silent until early 2006 when he reported left hip and pelvic pain.  He was found to have significant changes in the sacro-iliac joints ([SIJs] the joints between the lower spine and the pelvis).  This is concerning for ankylosing spondylitis.  A bone scan on 31 March 2006 confirmed the sacroiliitis and also a bursitis (inflammation of a fluid filled sac which reduces friction near joints) of the left hip (greater trochanter).  He also reported low back pain (LBP) and was referred to rheumatology.  He was initially seen in rheumatology on 25 July 2006 and underwent an evaluation which eventually led to the diagnosis of ankylosing spondylitis (AS).  Magnetic resonance imaging (MRI) of the lumbar spine on 15 August 2006 was significant for mild degenerative disc disease (DDD) and mild degenerative joint disease (DJD).  An MRI of the left hip on 3 January 2007 was significant for acute inflammatory changes with an effusion.  The CI was begun on Remicade (a medication used to treat auto-immune diseases such as AS) on 8 January 2007, and referred for physical therapy.  Formal range of motion (ROM) testing was done on 30 March 2007, shortly after the initiation of treatment and shows a significant reduction in lumbar flexion.  The CI reported reduced back and hip pain on the Remicade at a rheumatology follow-up appointment on 4 June 2007.  The ROM was reduced for the hips and back with the former painful, left > right.  He reported that he had recently been fired from the gym (maintenance worker) due to an inability to do his job well.  He was given an additional medication, Lyrica, for chronic pain.  An x-ray on 5 September 2007 of the lumbar spine was normal, but complete ankylosis (fusion) of the sacroiliac joints was seen.  The narrative summary (NARSUM) was dated 19 June 2007 and noted that the CI was pleased with the improvement in his symptoms on Remicade.  On examination, his gait was normal and the greater trochanters painful at the extremes of external rotation.  The left was painful to palpation.  He had full ROM bilaterally.  The ROM of the back was pain free, but the limits not recorded.  However, a normal gait implies a ROM within normal functional limits.  The neurological examination was normal and the previously noted muscle atrophy (wasting) was resolved.  He was diagnosed with chronic low back pain and bilateral hip pain from the AS.  

At the VA Compensation and Pension (C&P) examination performed on 16 November 2007, 2 months after separation, the CI reported that he had been given steroid injections for the trochanteric bursitis with benefit.  He had also been started on Humira, another disease modifying medication and now had pain free intervals and could easily climb 3-4 flights of stairs.  On examination, his gait was normal.  The ROM of the back and hips was reduced as charted below.  He was thought to have AS with complete ankylosis of the SI joints.  No specific diagnosis was made for the back or hips.  It was noted that x-rays of the hips on 16 November 2007, 2 months after separation, were normal.  An addendum dated 22 January 2008 noted that the MRI from 3 January 2007 had shown small osteophytes and narrowing of the left hip joint.  It was noted that the left greater trochanteric bursitis had resolved and the early arthritic changes were the likely cause of his hip pain.  A subsequent X-ray of the hips dated 10 April 2009, 19 months after separation, showed advanced degenerative disease of the hips.  

The goniometric 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)	PT/MEB ~6 Mo. Pre-Sep	NARSUM ~2 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep	
Flexion (90 Normal)	15	ROM pain free in all planes	40	
Combined (240)	135			
Comment	Obtained after 2 months Remicade Initiation	Normal neurological examination	Motion painful in some planes	
§4.71a Rating	40%	0%	20%	

Bilateral Hip ROM
(Degrees)	MEB ~6 Mo. Pre-Sep	NARSUM ~2 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep	
	Left	Right	Bilateral Hips	Left	Right	
Flexion (125 Normal)	115	115	Full ROM	125	110	
Extension (20)	15	20		---	---	
External Rotation (45)	25	30		25	45	
Abduction (0-45)	35	35		25	25	
Adduction (45)	20	30		45	45	
Comment	Limited by pain	Nml gait; painful left greater trochanter with palpation and bilateral pain at extremes of motion	Motion painful in some planes	Pain free motion	
§4.71a Rating	10%	10%	10%	10%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the CI for chronic low back and hip pain secondary to ankylosing spondylitis as a single combined condition, rated at 10%, and coded 5240 (ankylosing spondylitis).  The VA rated the ankylosing spondylitis of the SI joints at 20% using code 5240 and 5002 (rheumatoid arthritis).  It also rated each hip at 10% for osteoarthritis, coded 5099-5003 (analogous to degenerative arthritis).  The Board considered if the back and hip pain were separately unfitting.  The profile was for back and hip pain from a spondylo-arthropathy (a joint disease of the vertebral column [spine]) and the commander cited pain from both conditions.  However, while the NARSUM noted that the CI had bilateral hip pain at extremes of motion, he also had full ROM and a normal gait.  The examination for the back was essentially normal.  The ROM was not recorded, but full functional ROM is implied and it was pain free and the neurological examination was normal.  The CI reported to the C&P examiner that on his medication regime, he was able to climb 3-4 flights of stairs without difficulty and had a normal gait.  The ROM was reduced and painful in some planes of motion, but the level of limitation is not consistent with a normal gait or the reported level of function, reducing the probative value of the ROM value.  The VA C&P examiner noted that the hip bursitis was resolved and attributed the hip pain to mild degenerative changes seen on MRI in August 2006, but not on an X-ray in November 2007.  
The Board considered the totality of evidence and determined it does not support a finding that the back and hip were separately unfitting at separation.  It then considered the combined rating.  Ankylosing spondylitis is coded 5240 in the VASRD, a spine code.  The primary disability from AS is from pathology of the spine although other joints can be affected.  The VA noted that the CI had a normal gait and could climb 4 flights of stairs.  This is not entirely consistent with the limited ROM measured on the VA C&P, but there are no other values proximate to separation.  The MEB values were 6 months prior to separation and prior to treatment; accordingly, they are not thought to represent the level of disability present at separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 20% for the ankylosing spondylitis condition.  

BOARD FINDINGS:  In the matter of the chronic low back and hip pain diagnosed as ankylosing spondylitis condition, the Board unanimously recommends a disability rating of 20%, coded 5240, IAW VASRD §4.71a.  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, effective as of the date of his prior medical separation: 

 

CONDITION	VASRD CODE	RATING	
Chronic low back and hip pain…diagnosed…as ankylosing spondylitis 	5240	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140714, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160007998, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board's recommendation and record of proceedings (copy enclosed} and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,

Enclosure