RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00042
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070605

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Wheeled Vehicle Mechanic, medically separated for “chronic pain left ankle” and “sacroiliac joint injury,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Chronic pain that effects everything I do.”  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 - 20070502	VARD - 20070730	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Left Ankle	5099-5003	10%	Residuals of Left Ankle Pain and Stiffness	5099-5010	10%	20070501	
			Scars, Left Ankle	7802	0%		
Sacroiliac Joint Injury	5236	10%	Traumatic Arthritis of Right Sacroiliac Joint 	5242-5236	20%		
			Status Post Open Plating of the Symphysis Pubis for Pelvic Fracture 	5099-5010	10%		
			Scar, Anterior Pelvis	7802	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was involved a vehicular accident in March 2006 (15 months before separation) and sustained a left ankle fracture (bimalleolar) that required emergent surgery (open reduction with internal fixation [ORIF]).  Although there were ample records from the civilian facility managing the trauma (of limited probative value for ratable findings given the proximity to the injury), there was scant outpatient clinical evidence in from the service.  An earlier STR entry documented non-specifically decreased range of motion, and a later one recorded grossly normal range of motion (ROM) with painful motion.  Serial radiographic (X-rays) studies demonstrated good fracture healing and alignment with intact hardware and without specific mention of degenerative changes.

Surgical results were insufficient to allow unrestricted duty and the CI was referred for an MEB.  The MEB forwarded “left ankle fracture after open reduction and internal fixation with continued chronic ankle pain” for PEB adjudication.  

The MEB NARSUM examination on 22 March 2007 (2 months before separation) documented pain (referring to all injuries) “between 50% and 75% of the time” rated “3/10 at rest and 8/10 with prolonged walking or attempts at running.”  The physical examination recorded “a mildly antalgic gait” without attribution of the cause, well healed surgical scars, stability to stress testing, normal strength, and painful motion.  The MEB NARSUM addendum showed ROM measurements on the same date by physical therapy (PT) that documented dorsiflexion to 0 degrees (normal 20) and plantar flexion to 45 degrees (normal).

At the 1 May 2007 VA Compensation and Pension (C&P) examination, performed 1 month before separation, documented constant pain rated 4/10 that interfered with running and heavy lifting.  The physical examination recorded a “limp favoring left lower extremity,” non-tender surgical scars, non-specific joint tenderness, and normal motor strength.  Measured ROM was dorsiflexion of 20 degrees and plantar flexion of 40 degrees, specifying painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5099-5003 (analogous to degenerative arthritis) referenced the US Army Physical Disability Agency (USAPDA) pain policy.   The VA’s 10% rating (based on the C&P evidence) under code 5099-5010 (analogous to traumatic arthritis, defaulting to criteria of 5003) cited painful motion.  The VA additionally rated the left ankle surgical scar at 0% under code 7802 (scar(s), due to other causes).  The Board considered if the ROM limitation could be fairly characterized as “marked” in support of a 20% rating under code 5271 (limitation of motion), but members agreed that the near normal ROM measurements most proximate to separation (from the C&P) would not support that option.  Given the absence of ankylosis, nonunion or malunion, VASRD §4.71a offers no applicable joint code which would yield a rating higher than 10% for this case.  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 of the left ankle condition.
 
Sacroiliac Joint (SIJ) Injury.  In the 2006 vehicular accident the CI also suffered pelvic fractures (superior and inferior pubic rami fractures, pubic symphysis diastasis, right SIJ widening) that required emergent surgery (anterior and posterior pelvic ORIF).  As above for the ankle condition, there was a paucity of outpatient STR evidence.  Although it was apparent that there was right SIJ and right hip pain pursuant to the above pelvic fractures, there was no evidence (including in the initial trauma records) probative to distinguishing symptoms and limitations attributable to the spine or hip; or, to ratable findings for either one other than those below.  There was no STR (or VA) documentation of incapacitating episodes.  Serial X-rays demonstrated good fracture healing and alignment with intact hardware and mild degenerative changes.

Surgical results were insufficient to allow unrestricted duty and the CI was referred for MEB.  The MEB forwarded “pelvis fracture with sacroiliac joint and symphysis pubis disruption after open reduction and internal fixation with continued pelvic pain/sacroiliac joint pain” for PEB adjudication.  

The MEB NARSUM likewise did not differentiate SIJ or hip complaints and provided only an overall pain characterization as per the ankle evidence.  In addition to the gait disturbance and other relevant findings from above, the physical examination recorded right SIJ tenderness, “a positive Patrick test” (specific to hip pathology), and full ROM of the hip.  The physical examination did not elaborate any specific lumbosacral findings or ROM.  There were, however, PT ROM measurements for MEB NARSUM for both the right hip (same day as NARSUM) and thoracolumbar spine (5 weeks later).  The ROM measurements for the hip were flexion to 100 degrees (normal 125, 45 for minimum 10%), extension to 20 degrees (normal), and abduction to 30 degrees (normal 45, 10 for minimum 10%), specifying painful motion.  The lumbar ROM measurements were flexion to 40 degrees (normal 90) with a combined ROM of 160 degrees (normal 240).

At the 1 May 2007 VA C&P examination, performed 1 month before separation, also did not differentiate SIJ or hip pain, but addressed a single condition labeled “pelvis fracture.”  The examiner documented constant pain rated 4/10 that prohibited running, jumping, and heavy lifting.  The VA C&P physical examination did not address specific findings for the hip, SIJ or spine, other than the presence of a non-tender pelvic surgical scar and normal motor and sensory testing.  The VA C&P did not provide ROM measurements for the hip or thoracolumbar spine.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5236 (sacroiliac injury and weakness, defaulting to criteria of the §4.71a general spine formula) cited “thoracolumbar [ROM] limited by pain,” consistent with application of Army Regulation 635-40 (B-29, e).  Although the VA C&P examiner did not specify separate conditions or diagnoses, the VA provided separate ratings for the pelvic fractures.  One was for the SIJ rated 20% under code 5242-5236 (degenerative arthritis of the spine-sacroiliac injury and weakness), referencing the service PT thoracolumbar ROM measurements that satisfied the 20% spine formula criterion of “limitation of flexion (greater than 30 degrees but not greater than 60 degrees).”  The other was for the right hip rated 10% under code 5099-5010 (same as ankle) which also referenced the service PT ROM measurements and cited painful motion.   The VA additionally rated the anterior pelvis surgical scar at 0% under code 7802 (scar(s), due to other causes).   

Members first deliberated if separate SIJ and right hip conditions could be justified for separate service ratings.  Although the MEB’s diagnostic description was encompassing enough to extrapolate both conditions, and the MEB NARSUM examination concentrated on hip findings, the PEB’s coding and rating decision precluded a service determination that there was an unfitting and service ratable hip condition.  Members thus concluded that it was not justified by the Board’s scope purview (as elaborated above) to recommend an additional hip condition subject to separate service rating.  Furthermore it was considered that there was not enough directed evidence in this case to identify functional impairment specific to either the SIJ or hip to provide a basis for determining separate unfitness.  It would in fact be equivocally compliant with VASRD §4.14 (avoidance of pyramiding) to attribute painful motion (the only compensable finding) to the uninvolved hip joint without implicating the SIJ and other pelvic injuries.

The Board members then deliberated the appropriate rating of the SIJ condition.  Code 5236 is quite specific for the condition and the Board is bound by the applicable VASRD criteria.  As noted above, the only available ROM evidence (from the VA C&P) satisfied a 20% rating criterion for the code.  There was no evidence of additionally ratable peripheral nerve impairment, and no documentation of incapacitating episodes or diagnosis of intervertebral disc syndrome that would provide for a higher rating under that formula.  After due deliberation, considering all evidence and with deference to reasonable doubt, the Board recommends a 20% rating for the SIJ condition under code 5236.

BOARD FINDINGS:  In the matter of the left ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the pelvic fractures and right sacroiliac condition, the Board unanimously recommends a Service disability rating of 20%, coded 5236 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain with Surgical Residuals, Left Ankle	5099-5003	10%	
Pelvic Fractures with Right Sacroiliac Disruption	5236	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150115, 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

06 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002955 (PD201500042)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with [severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA