RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 		CASE:  PD-2014-04184
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Petroleum Specialist) medically separated for “chronic low back pain” and “left iliotibial band syndrome,” rated 10% and 0%, respectively. 

CI CONTENTION:  She is in constant pain and the condition continues to impact her daily activities.  Her 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 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 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 20030228	VA* - (~1 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5295	10%	Mechanical Low Back Pain with Left Sacroilitis	5299-5295	10%	20030610	
Left Iliotibial Band Syndrome	5314	0%	Iliotibial Band Syndrome, Left Hip	5299-5252	10%	20030610	
Conditions x 0 (Not in Scope)	Other x 2	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20030627 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  The Board is required to recommend a rating IAW the VASRD in effect at the time of separation in accordance with DoDI 6040.44.  The Board noted that the 2003 Veteran Administration Schedule for Rating Disabilities (VASRD) standards for the spine, which were in effect on the date of separation, were changed to the current §4.71a rating standards effective September 26, 2003.  The Board must correlate the above clinical data with the 2003 rating schedule; applicable diagnostic codes include: 5292 (limitation of lumbar spine motion); 5293 (intervertebral disc syndrome; based on incapacitating episodes); and 5295 (Lumbosacral strain).  The 2003 criteria relevant for consideration in the Board’s recommendation are cited in context below. 
Chronic Low Back Pain Condition.  The narrative summary (NARSUM) noted the CI had a history of low back pain (LBP) since August 2001 which was diagnosed as a strain and treated with medications.  There were scant notes in the available service treatment record.  The CI gave birth in July 2001 and following childbirth the she experienced left sided pain from the pelvis to the outside of the knee diagnosed as iliotibial band syndrome (ITBS).  The CI was treated with medications and physical therapy for the ITBS (discussed further below).  The CI was deployed and continued to have pain thought due to ITBS and in approximately September 2002 after return from deployment, she reported her LBP, which seemed to be closely related to the hip pain, was worsening.  The LBP was thought related to sacroiliac joint (SIJ) dysfunction, left greater than right, and/or possibly lumbar disc related.  Lumbar spine X-rays and magnetic resonance imaging were normal.  Physical therapy treatment, including for SIJ dysfunction, provided minimal relief and a MEB was an initiated.  At the MEB exam on 3 February 2003, the CI reported LBP and left hip pain.  The MEB physical exam noted the CI was able to heel and toe walk.  There was normal alignment of the spine and pelvis and straight leg raise (SLR) testing was negative.  There was TTP on the left side of the lumbosacral spine and left hip.  The DD Form 2808, Report of Medical Examination, dated 15 April 2003, noted TTP of the lower thoracic and upper lumbar spine increased by upper extremity motion with full ROM and pain on rotation.  Supine SLR caused back pain only and seated SLR did not cause pain.  At the VA Compensation and Pension (C&P) exam on 10 June 2003, the CI reported constant LBP, increased with activity or prolonged sitting and relieved by ice and lying flat.  The exam noted a normal gait and normal strength and reflexes throughout.  The TL spine exam was otherwise reported exactly as reported on the DD Form 2808.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the low back condition 10%, coded 5299-5295 (analogous to lumbosacral strain).  The Board agreed that the low back condition met a 10% rating coded as 5295 according to the VASRD rules for rating the spine in effect on the date of separation (as elaborated above) for “characteristic pain on motion” and did not meet the next higher evaluation of 20% for “muscle spasm on extreme forward bending, loss of lateral spine motion…in standing position.”  The Board reviewed to see if a higher evaluation was supported with any other spine code in use at the time of separation.  Members agreed that the full ROM noted on the DD Form 2808 and at the C&P exam was best characterized as `slight’ limitation of ROM, rated 10% and not `moderate’ as for the 20% rating.  Additionally, there was neither evidence of incapacitating episodes, defined as bed rest prescribed by a physician and treatment by a physician,” nor of “chronic neurologic manifestations” to support higher evaluation coded as 5293 (intervertebral disc syndrome).  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 condition.  

Left Iliotibial Band Syndrome Condition.  The narrative summary (NARSUM) noted the CI developed left side pain from the hip to the knee following childbirth in July 2001.  She was diagnosed with iliotibial band syndrome (ITBS) and was treated with medications and therapy.  A physical therapy visit prior to being deployed noted that the CI continued with diffuse knee pain.  She deployed in 2002 and following return she was evaluated by an orthopedic specialist who agreed with the diagnosis of ITBS and injected the left hip for bursitis due to ITB friction.  Left hip and femur X-rays were normal.  Despite continued physical therapy the left leg pain did not resolve.  At the MEB exam, the CI reported left hip and knee pain.  The MEB physical exam noted  a normal gait.  There was TTP of the left hip.  There was full ROM of the left knee without swelling, effusion, or crepitus.  The DD Form 2808 noted lateral patellar crepitus of the left knee, with normal ROM and lateral hip pain with knee and hip ROM.  The examiner noted diagnoses of retropatellar pain syndrome (RPPS) and ITBS.  At the VA Compensation and Pension (C&P) exam the CI reported pain on the outside of the left knee aggravated by prolonged sitting and intermittent left thigh numbness with walking.  The CI also reported that she had fallen on her knees after the birth of her child due to giving way of the LLE.  The exam noted normal posture and gait.  There was full ROM of the hips with lateral left hip pain with hip and simultaneous knee flexion.  There was full ROM of the left knee with patellar crepitus.  Hip and Knee X-rays were normal.  The VA examiner also noted diagnoses of RPPS and ITBS of the left knee.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the ITBS condition 0%, coded 5314 (Group XIV muscle injury) and the VA rated it 10%, coded 5299-5252 (analogous to limited thigh flexion), citing ITBS, left hip and provided a 10% rating for the left knee, coded 5299-5260, citing retropatellar pain syndrome of the left knee.  The Board noted that the evidence in record supports that the CI was diagnosed with left hip and knee pain related to ITBS.  The iliotibial band (ITB) is a band of fibrous tissue that connects hip muscles to the tibia at the level of the knee and is involved in movement of the hip and knee.  ITBS is a common overuse injury that usually causes lateral knee pain, but can cause pain primarily at the hip or along the whole course of the ITB.  On the DD Form 2808 the examiner noted RPPS and ITBS, as did the at C&P examiner.  At both the DD Form 2808 and C&P exams knee and hip ROM was normal and no abnormalities were noted on hip and knee X-rays.  The Board considered that the symptoms of the ITBS at the MEB and C&P exams was tenderness along the course of the ITB, with only hip pain with ROM of the hip and knee.  The Board deliberated whether multiple ratings could be provided for knee and hip pain due to ITBS, but  agreed that the ITBS condition could only be provided a single rating IAW VASRD 4.14 (Avoidance of pyramiding) because “the evaluation of the same disability under various diagnoses is to be avoided.”  

The Board first reviewed the 5314 rating criteria, which are subjective, with a 0% rating for ‘slight,’ 10% rating for ‘moderate,’ 30% for ‘moderately severe,’ and 40% for ‘severe’ muscle injury.  The Board considered that when coding the disability due to ITBS analogously as 5314, the discrimination between the ‘slight’ and ‘moderate’ characterizations depends on the presence of at least one cardinal sign or symptom of muscle injury specified as “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement” for ‘moderate,’ as opposed to none for ‘slight.’  In the STR and at the MEB examination and C&P exam, the CI reported lateral leg pain that spanned the hip to the knee.  Therefore, the Board concluded that based on the presence of the cardinal symptom of fatigue-pain, the disability due to the ITBS was best described as ‘moderate’ and not ‘slight’ and met the 10% rating, but judged it could not be characterized as ‘moderately severe,’ which by analogy Board members judged would require more severe symptoms and greater objective evidence of muscle injury such as weakness or atrophy.

The Board also agreed the evidence supports a 10% rating IAW VASRD 4.71a (musculoskeletal conditions), coded as 5299-5024 (analogous to tenosynovitis) involving two major joints, or coded as 5299-5252 for painful hip ROM IAW VASRD 4.59 (painful motion) or alternatively it could be rated 10% coded as 5299-5260 (analogous to limited knee flexion).  The Board reviewed to see if any alternative coding approach resulted in a higher rating.  There was no evidence of limited hip or knee ROM sufficient to support a higher rating of either joint based on ROM alone and there was no other ratable impairment of the hip in evidence in this case.  The Board discussed the RPPS diagnosis of the left knee made during the MEB process, and noted that there was no evidence that RPPS was a separately unfitting condition.  Moreover, any contribution to knee pain from RPPS could not be separated from knee pain due to ITBS and as noted above IAW with §4.14, additional rating of the knee was not supported on this basis and there was no other ratable impairment of the knee in evidence in this case.  The Board thus determined that the ITBS condition could be rated 10% and no higher, and chose to code as 5299-5024 because ITB caused pain at the level of two major joints.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the ITBS condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5024 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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain Condition	5299-5295	10%	
Left Iliotibial Band Syndrome Condition	5099-5024	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140512, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160005176, 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.

Sincerely,

Enclosure