RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03871
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081022

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Unit Supply Specialist, medically separated for “sacroiliac injury and weakness,” with a disability rating of 10%.

CI CONTENTION:  “Condition has gotten worse.”  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 - 20080917	VARD - 20090916  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Sacroiliac Injury and Weakness	5236	10%	Right Sacroiliitis, Mild	5236	10%	20090904	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Sacroiliac Injury and Weakness.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s sacroiliac condition began in September 2007, approximately 4 months after enlistment.  She reported no previous back problems, but experienced back pain with occasional radiation down the right leg to the knee after more aggressive physical training, without numbness, tingling, or weakness of the lower extremities or bowel or bladder problems.  Imaging studies demonstrated an abnormal transitional vertebra at L5, with incorporation of the transverse process of the L5 vertebra into the right sacroiliac joint (SIJ).  Bone scan noted increased uptake in the right SIJ and right L5 vertebra.  The CI was evaluated by chiropractic, orthopedic, physical medicine, and pain medicine specialists.  She was diagnosed with sacroiliitis and congenital abnormalities of the lumbosacral spine with service aggravation.  No surgery was indicated and conservative treatment failed to improve her back pain.  The MEB forwarded “sacroiliitis with radiographical evidence of spina bifida” 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.  

Thoracolumbar ROM
(Degrees)	PT/MEB                         ~4 Mos. Pre-Sep	MEB                            ~3 Mos. Pre-Sep	VA C&P                ~10 Mos. Post-Sep	
Flexion (90 Normal)	85	90	90	
Combined (240)	220	-	240	
Comments	Painful motion, no muscle spasm, normal gait and spinal contours	Painful motion, + muscle spasm, normal gait, - SLR TTP	Tenderness	
§4.71a Rating	10%	10%	10%	

The MEB NARSUM examination on 6 August 2008, 3 months prior to separation, the CI reported chronic low back pain with occasional numbness down the right hip.  On physical examination there was a normal gait.  There was tenderness to palpation (TTP) and muscle spasm of the right lumbar region. Back range of motion (ROM) was “adequate” with flexion of 90 degrees with pain noted.  There was TTP of the right SIJ.  There was somatic dysfunction of the pelvic bone with subluxation of the anterior symphysis pubis.  Lower extremity strength, sensation, and reflexes were normal. The remainder of thoracolumbar ROM was as measured by physical therapy (PT), 4 months before separation, in the chart above.

At the 4 September 2009 VA Compensation and Pension (C&P) evaluation, performed 10 months after separation, the CI reported chronic right SIJ pain with stiffness and spasm.  She reported intermittent tingling in the right lower extremity in a “stocking distribution” (non-radicular).  The CI reported daily flare-ups with lifting.  She was employed at a deli and lifted heavy boxes several times per day.  There were no incapacitating episodes in the last 12 months.  Physical examination showed a normal gait, lower extremity strength, sensation, and reflexes were normal, and SLR was negative.  There were no abnormal spinal curvatures.  The CI moved throughout the examination and was able to heel and toe without difficulty.  There was no pelvic asymmetry noted.  There was TTP of the right SI joint.  There was no TTP of the thoracolumbar spine or muscles and no guarding or spasm.  Thoracolumbar ROM was as noted in the chart above.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the sacroiliac condition 10%, coded 5236 (sacroiliac injury and weakness).  The PEB cited TTP and muscle spasm.  The PEB also indicated that spina vertebral anatomy abnormalities existed prior to service (EPTS), but were service aggravated with an undetermined EPTS factor.  The VA rating was based on the VA C&P examination 10 months after separation and cited full motion with pain.  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 combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT MEB and MEB NARSUM examinations.  Although there was muscle spasm noted at the MEB NARSUM examination, but not the PT MEB or VA C&P examinations, 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.  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 “sacroiliac injury and weakness” condition.  

Contended PEB Conditions: Depression, Abnormal EKG, and Flat feet.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The depression, abnormal EKG, and flat feet were not profiled or implicated in the commander’s statement and were not 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.  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 any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the sacroiliac injury and weakness condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended depression, abnormal EKG, and flat feet 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 20140829, w/attachments
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

07 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
 (PD201403871)

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