RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04325
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020605

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E2, Advanced Individual Training Student, medically separated for “bilateral lower extremity pain and low back pain,” with a disability rating of 10%.  

CI CONTENTION:  Her conditions continue to worsen.  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 - 20020419	VARD - 20030915	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Pain and Low Back Pain	5099-5003	10%	Radiculopathy Left Leg…	5295-8520	20%	20020909	
			Bursitis Left Hip	5019-5252	10%		
			Lumbar Strain	5295	10%		
			Left Knee Condition	5257	NSC		
			Left Ankle Condition	5271			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity Pain and Low Back Pain (LBP).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI began her enlistment on 3 April 2001 at which time the accession paperwork documented her to be overweight and to exceed body fat standards, but was able to lose weight to be within standards.  She did not pass the initial Army Physical Fitness Test (APFT) on 14 April 2001, but improved over the next few months in all three categories and she achieved a total point score of 207 on the final APFT before she was placed on profile.  The first record in evidence is a duty limitation slip for hip pain dated 15 June 2002.  This was thought to be an overuse injury.  An X-ray on 29 June 2001 of the left hip was normal.  The request noted a 1-2 month history of pain with activity and an abnormal gait.  A bone scan, for hip pain, on 3 July 2001 documented mild stress changes (without fracture) of both knees, ankles, feet, and shin bones.  No comment was made on the back or hips implying that these were normal.  The CI was treated with duty restrictions, physical therapy (PT), and the use of crutches without resolution of her hip pain or LBP which was noted in early July.  The MEB forwarded “chronic recurrent low back pain” and “stress reactions bilateral lower extremities” for PEB adjudication.  

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated September 2001, 9 months prior to separation, the physical examination was normal.  On the history, LBP radiating to the hip was noted since June 2001.  An X-ray of the lower back on 17 October 2001 showed mild degenerative disc disease (DDD) at L4-5.  An evaluation by orthopedics on 23 October 2001 noted that the examination of the back and lower extremities was normal.  In primary care on 10 November 2001, the examiner was unable to reproduce the ankle or knee pain.  It was noted that the CI was in the process of an MEB for the LBP.  An MRI of the lower back, accomplished on 13 December 2001 and a more sensitive test for DDD than an X-ray, was normal.  A PT examination on 15 January 2002 noted that the gait was abnormal secondary to pain.  Lumbar flexion was to the knees.  Rotation and side bending were normal.  Tenderness was present.  

The MEB NARSUM examination on 3 March 2002, 3 months prior to separation, noted the onset of LBP in May 2001 during basic training.  The CI reported that she was on a confidence course and fell onto a log, striking her back.  She stated that 75% of her pain was in the back and 25% in the left hip.  On examination, she had a normal gait and neurological examination.  The range of motion (ROM) was not recorded, but prior clinical notes indicated normal or near normal ROM.  Motion was painful.  Tenderness and spasm were absent.  The examination of the knees, ankles, and feet was normal.  No specific comment was made regarding the hip although the muscles of the hip (which were listed) were noted to be normal.  The CI was diagnosed with chronic recurrent LBP and stress reactions in both lower extremities.  It was thought that her LBP would improve, but that she would be susceptible to future stress reaction and retention was not recommended.  

At the 9 September 2002 VA Compensation and Pension (C&P) evaluation performed, 3 months after separation, the CI reported that she had fallen onto her back in May 2001.  She also reported left knee and ankle pain which she attributed to her back condition.  On examination, she had a slight limp.  The examination of the back showed painful but full ROM.  The motor function was normal and the general neurological examination recorded as non-focal (implying that there was not a radiculopathy).  The examinations of the (left) knee and ankle were normal.  X-rays of the back, left knee, and left ankle were normal.  

The PEB combined bilateral lower extremity (BLE) pain and low back pain (LBP) as a single condition coded analogously to degenerative arthritis (5099-5003) and rated it at 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  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.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 DES 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 Board directed attention to its rating recommendation based on the above evidence.  It first considered if the lower extremities were separately unfitting from the back condition.  It noted that a bone scan in July 2001, almost 1 year prior to separation, showed mild stress changes (without fracture) of both knees, ankles, feet, and shin bones.  X-rays of the left hip, knee, and ankle were normal though.  On the NARSUM examination, no direct comment was made about the hips or the shins.  The knees, ankles, and feet were specifically noted to be normal.  The Board also noted that the commander only commented on the back condition and that the profile did not specify any particular joint in the lower extremities, but noted the stress reactions.  Stress reactions are seen with over-use and typically resolve when the stress is removed.  The Board noted that the CI only reported pain in the left knee and ankle at the VA C&P examination and had a normal examination.  The evidence does not support the addition of the bilateral lower extremity stress reactions as a separately unfitting condition.  

The Board then considered the rating for the LBP.  The PEB rated the back condition at 10%, analogously coded 5099-5003 (degenerative arthritis), citing pain slight and frequent. The VA rated the back condition 10% coded 5295 (lumbosacral strain), based on the VA C&P examination 3 months after separation, citing limited lumbar motion with 90 degrees of flexion and 20 degrees of extension.  The VA also rated the radiculopathy of the left at 20%, analogously coded 5295-8520 (moderate incomplete paralysis of the sciatic nerve), citing evidence from an examination dated 31 July 2003, over 1 year after separation.  The CI was separated on 5 June 2002 when the old spine rules were in effect.  Painful motion was present to support a 10% rating.  The neurological examination, when documented, was normal and the findings do not support the presence of an unfitting radiculopathy at separation.  The Board found no route to a higher rating for the back condition at separation.  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 bilateral lower extremity pain and LBP condition.  

BOARD FINDINGS:  In the matter of the bilateral lower extremity pain and LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
AR20160018404 (PD201404325)

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