RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03685
BRANCH OF SERVICE:  Army 	SepAration date:  20040612

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Medical Technician, medically separated for “low back pain (LBP) and bilateral hip pain…,” with a disability rating of 10%.  

CI CONTENTION:  The CI requested consideration of all conditions. 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 on 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 –20040414	VARD - 20050119	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain and Bilateral Hip Pain…	5299-5237	10%	Lumbosacral Strain	5237	10%	20040819	
			R Femoral Neck Stress Fracture	5099-5022	0%	20040819	
			L Femoral Neck Stress Fracture	5099-5022	0%	20040819	
Rectal Bleeding	Not Unfitting	Rectal Bleeding/Hemorrhoids**	7336	10%	20050218	
Hypothyroidism	Not Unfitting	Not Service Connected (NSC)	
Occupational Problems	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	
**Deferred at separation.  10% later awarded retroactive to separation.  

ANALYSIS SUMMARY:  

Low Back and Bilateral Hip Pain.  The CI reported the onset of left greater than right hip pain during Advanced Infantry Training.  She was treated with duty restrictions and began a running program on her own in December 2002 with recurrent symptoms.  A bone scan on 27 January 2003 showed bilateral stress related changes.  She was treated with duty medications and also issued crutches.  The latter led to LBP and were discontinued.  Duty modifications were continued and she was referred for acupuncture, physical therapy, and chiropractic treatment.  A repeat bone scan on 29 September 2003 showed persistent stress related changes thought to show an enthesopathy (a disorder of the tendon attachment to a bone rather than a problem with the spine or hip joints themselves).  In Sports Medicine on 26 November 2003, she was noted to have chronic LBP and pelvic and hip pain which had not adequately responded to treatment and a Medical Evaluation Board (MEB) was initiated.  The narrative summary (NARSUM) was dated 10 December 2003, 6 months prior to separation.  The CI reported back and bilateral hip pain which was not related to any particular activity.  On examination, the range of motion (ROM) of the hips and back was painful.  Decreased strength was recorded at 4/5.  

At an orthopedic addendum to the NARSUM on 7 January 2004, 5 months before separation, she reported back and bilateral hip pain (50% each) with radiation of the pain down her legs to her knees and feet.  She endorsed deconditioning and global weakness, but no weakness specific to her back or legs.  She was able to swim, walk, and use a “glider,” but could not run.  On examination, her gait and back ROM were normal.  Reflexes and strength were normal.  The sensation of the right leg was diminished over the entire leg (non-radicular).  She was tender over the lumbar muscles and both hips.  X-rays of the lumbar spine, pelvis, and hips were normal.  She was thought to have an enthesopathy.  Magnetic resonance imaging (MRI) (not in evidence) of her spine and pelvis in 2003 had been unremarkable.  

At the VA Compensation and Pension (C&P) examination performed on 19 August 2004, 2 months after separation, the CI reported flare ups of pain every 2-3 months which were independent of activity.  She did not use an assistive device and incapacitation for the hips was not recorded, but she did report 2 days of incapacitation for the back over the past year.  She reported flare ups of pain with extensive walking, but none for 2-3 months.  She as able to use the elliptical trainer for 30 minutes 4-5 times a week without discomfort.  On examination, she had minimal tenderness over the left hip.  The ROM was normal for the hips other than adduction (crossing one leg over the other).  Painful motion was not recorded.  Flexion and extension of the back were both limited by 10 degrees (80 and 20, respectively) and painful.  The ROM of the back was otherwise normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the LBP and bilateral hip pain conditions as a single unfitting condition analogously coded 5299-5237 (lumbosacral or cervical strain) and rated at 10%.  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.  When considering a separate rating for each condition, the Board considers 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.  The evidence for the LBP and bilateral hip pain conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  
  
The Board first considered if the back and hips were separately unfitting.  It noted that while the CI complained of LBP after the use of crutches, her examination was consistently normal or essentially normal.  The bone scans, X-rays, and MRI of the back were all unremarkable.  The evidence did not support a finding that the back was separately unfitting.  The Board then considered the bilateral hip pain condition.  The bones scans showed stress reactions (but not stress fractures) and X-rays were normal.  She was diagnosed with an enthesopathy rather than a problem with the hip joint itself.  She had a normal gait and essentially normal ROM.  She was able to use an elliptical trainer for 30 minutes at a time 4-5 times a week without problems.  The evidence did not support a finding that the hips were separately unfitting either.  The PEB rated the CI at 10%, coded 5299-5237 (analogous to lumbosacral strain), for the LBP and bilateral hip pain condition, for local tenderness.  The VA rated the back at 10% also coded 5237.  It also rated the hip pain condition at 0%, coded 5099-5022 (periostitis), for left and right femoral neck stress fractures.  The Board observed that the CI did not actually have stress fractures, but stress reactions and the orthopedist determined that this was most likely of the tendons at the bony attachments.  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 LBP and bilateral hip pain condition.  

Contended PEB Conditions:  Hypothyroidism, Rectal Bleeding and Occupational Problems.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The hypothyroidism condition existed prior to service and was declared at accession.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the low back pain and bilateral hip pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypothyroidism, rectal bleeding, and occupational problems 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 20140612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXX, AR20160011586 (PD201403685)

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