RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03517
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090313

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Indirect Fire Infantryman, medically separated for “right hip pain” and “low back pain [LBP],” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI’s condition continues to worsen and negatively impacts daily activities.  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 based upon a 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 - 20090224	VARD - 20090529	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Hip Pain	5099-5003	10%	Right Hip Degenerative Arthritis	5003-5251	10%	20090325	
Low Back Pain	5299-5237	10%	Mild Facet Hypertrophy at L5-S1	5242	10%		
Daily Gastroesophageal Reflux	Not Unfitting	Gastroesophageal Reflux Disease	7399-7346	10%		
Elevated Blood Pressure		Elevated Blood Pressure	7101	NSC		
Impaired Fasting Glucose		Impaired  Fasting Glucose 	7999-7913	NSC		
History of Furuncle Infected with MRSA		Furuncle Infected with Methylcillin-Resistant Staphylococcus Aureus (MRSA)	7899-7828	NSC		
Chronic Right Shoulder Pain		Right Shoulder Strain	5201	NSC		
Bilateral Dorsal Foot Pain		Superior Calcaneal Spur, Right Foot	5284	10%		
		Superior Calcaneal Spur, Left Foot	5284	10%		
		Pes Planus	5276	NSC		
Mild Shin Splints		Shin Splints, Left	5299-5262	10%		
		Shin Splints, Right	5299-5262	10%		
Right Wrist Pain		Right Wrist Condition	5215	NSC		
Frequent Palpitations		Heart Condition with Frequent Palpitations	7099-7010	NSC		
Intermittent, Bilateral Tinnitus		Tinnitus	6260	10%	20090324	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Right Hip Pain Diagnosis.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hip condition began in early 2005 while deployed and worsened after a 12-mile ruck march.  Imaging, including X-rays and magnetic resonance imaging (MRI) of the right hip and pelvis, were normal.  The CI deployed again in 2006 and completed the full deployment; however, after return from deployment the hip pain worsened with running and in in early 2008 he again aggravated the right hip when he jumped off a vehicle.  He participated in multiple courses of physical therapy throughout this time without improvement.  The MEB forwarded “chronic right hip pain” for PEB adjudication.

The range of motion (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.  

DOS 20090331
Right Hip (Thigh) ROM
(Degrees)	MEB ~5 Mos. Pre-Sep
(20081106) p.79	VA C&P ~6 Days Pre-Sep
(20090325) p.370	
Flexion (125 Normal)	109, 111, 111	90	
Extension (20)	1, 6, 6	30	
External Rotation (45)		60	
Abduction (0-45)	31, 35, 32	45	
Adduction (45)		25	
Comment	Painful motion	Tenderness 	
§4.71a Rating	10%	10%	

The MEB physical examination dated 6 November 2008, 4 months prior to separation, noted the right hip appeared normal.  There was no tenderness to palpation (TTP).  Squatting caused pain and ROM was decreased as noted in the chart above.  All ROM was limited by pain.    

The MEB NARSUM examination on 22 December 2008, 3 months before separation.  The CI reported no medications for the hip condition.  He reported right hip pain present for 80% of the day, graded 2-4/10, aggravated by activity.  He reported his hip was not painful at the examination because he had not participated in any physical training over the last month.  The CI reported flares several times per day, especially at the end of the day with pain graded 7/10.  The MEB NARSUM examination cited the findings of the MEB examination as summarized above.

At the VA Compensation and Pension (C&P) examination in 25 March 2009, 2 weeks after separation, the CI reported chronic right hip pain graded 2/10, aggravated by activity.  Physical examination showed right hip TTP, without swelling, effusion, weakness, subluxation or guarding of movement.  Right hip ROM was a noted in the chart above.  There was no decrease in the ROM after repetition.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis), citing painful motion and functional loss.  The VA also assigned a 10% rating coded 5003-5251 (degenerative arthritis-limitation of thigh extension)) based on the VA C&P examination 2 weeks after separation, citing painful motion.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of thigh flexion or extension, thigh impairment (5251, 5252).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The examinations proximate to separation did not demonstrate the presence of hip ankyloses, flail hip joint, of femur impairment (5250,5254, 5255) for a rating under the respective codes.  There was therefore no route to a rating higher than the 10% adjudicated by the PEB under any applicable VASRD §4.71a code.  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 for the right hip condition.  

LBP Diagnosis.  According to STR and the MEB NARSUM, the CI’s LBP condition began in summer of 2007 while deployed, when he specifically injured his back while clearing a house in full gear.  The CI completed his deployment with intermittent LBP.  Following return from deployment the CI experienced repeated aggravation of the LBP with muscle spasm despite profile limitations.  Imaging including X-rays and MRI of the spine “mild” degenerative changes.  The MEB forwarded “chronic, nonradicular low back pain” for PEB adjudication.

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.  

DOS 20090331
Thoracolumbar ROM
(Degrees)	MEB ~5 Mos. Pre-Sep
(20081106) p.80	VA C&P ~6 Days Pre-Sep
(20090325) p.371	
Flexion (90 Normal)	91, 86, 88	80	
Extension (30)	28, 27, 30	20	
R Lat Flexion (30)	40, 40, 41	20	
L Lat Flexion (30)	40, 38, 37	20	
R Rotation (30)	41, 45, 43	20	
L Rotation (30)	63, 58, 55	20	
Combined (240)	237, 233, 238	180	
Comment	Tenderness, pain, Muscle spasm, normal gait, neg SLR, nl spinal contours 		
§4.71a Rating	10%	#%	

The MEB physical examination dated 6 November 2008, 4 months prior to separation, noted thoracolumbar range of motion (ROM) as noted in the chart above, with pain noted.  There was muscle spasm and tenderness without abnormal spinal contours or abnormal gait.  Straight leg raise (SLR) testing to elicit radicular symptoms was negative.  At the MEB NARSUM examination the CI reported no medications for the hip condition.  Lower extremity strength, sensation, and reflexes were normal 

At the VA Compensation and Pension (C&P) examination in 25 March 2009, 2 weeks after separation, the CI reported localized LBP and stiffness, without numbness or bowel/bladder problems.  The CI graded the pain level 3/10 aggravated by activity and relieved by rest.  There were no capacitating episodes reported in the 12 months before separation.  The physical examination noted a normal posture and gait.  There was no muscle spasm or evidence of radiating pain with movement.  There was negative SLR.  Thoracolumbar ROM was as noted in the chart above, with painful motion noted.  Lumbar spine X-rays showed “minimal” degenerative disc disease and spinal arthritis.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5237 code (lumbosacral strain), citing functional loss considerations.  The VA also assigned a 10% rating using the 5242 code (spinal arthritis) based on the VA C&P examination 2 weeks after separation, citing limitation of motion.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB and VA examinations proximate to separation.  Although there was muscle spasm noted on the MEB exam, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  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 for the low back pain condition.

Contended PEB Conditions.  Gastroesophageal reflux disease (GERD) elevated blood pressure, impaired fasting glucose, furuncle, chronic right shoulder pain, bilateral foot pain, mild shin splints, right wrist pain, frequent palpitations and intermittent, bilateral tinnitus.  None of the listed contended conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 any of the listed contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matters of the right hip pain and the low back pain conditions IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudications.  In the matter of the contended GERD elevated blood pressure, impaired fasting glucose, furuncle, chronic right shoulder pain, bilateral foot pain, mild shin splints, right wrist pain, frequent palpitations and intermittent, bilateral tinnitus conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20140723, 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

21 NOV 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
, AR20160017501 (PD201403517)

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.

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA