RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00398
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050602

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Food Service Specialist, medically separated for “low back and pelvic pain on the right side” 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 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 - 20050505	VARD - 20060104	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back and Pelvic Pain on the Right Side…	5236	10%	Right Sacroiliitis	5236	0%	20051011	
			Right Hip Pain	5250	NSC	20051011	
			Left Hip Pain	5250	NSC	20051011	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Low Back and Pelvic Pain on the Right Side.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back and right side sacroiliac joint (SIJ) pain condition began in June 2003 after hurdling an obstacle on an obstacle course at basic training.  The CI developed right side low back pain (LBP) with radiation down the right leg.  Radiographic [X-ray] studies showed a normal pelvis with some sclerosis of the SIJ on the right.  Bone scans showed increased uptake at the right SIJ and the CI was diagnosed with a stress induced reaction of the right SIJ.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “low back and pelvic pain on the right secondary to stress induced sacroilitis” for PEB adjudication.

The MEB NARSUM examination on 8 March 2005 (3 months prior to separation) noted persistent complaints of increased SIJ pain with increased physical activity, with intermittent radiation.  Physical examination showed the CI walked with a slight antalgic gait secondary to pain at the right SIJ.  There was some paravertebral muscle spasm at the right side.  There was tenderness to palpation (TTP) at the SIJ and at the insertion of the gluteal muscles on the right side.  The CI had full ROM of the low back as well as the hips.   She could bend forward and bring the fingertips to within 5 centimeters (~ 2inches) of the floor.  She had discomfort with straight leg raising testing.  The reflexes were bilaterally equal and prompt.  The strength was equal right and left at 5/5.  There were no neurological deficits.  She had difficulty arising from chairs secondary to pain at the SIJ.  The MEB NARSUM examiner noted that the most recent bone scan showed a decrease in the previously noted stress induced reaction and attributed it to the CI’s restrictive profile.  Laboratory studies showed no evidence of rheumatologic disease.  

At the 11 October 2005 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported pain to the entire right side buttock region, left side pubic and groin region pain.  She reported being hospitalized 5 times in the past 12 months because of her pain.  She also reported being given quarters three times.  She reported paresthesias from her hip to her toe approximately 1 time per week after over activity or after sleeping wrong.  She stated her back region swells and that she had weakness to the right side of her back and leg, especially with swimming.  She also reported spasm.  She denied left lower extremity pain.  She reported sharp pain through the SIJ bilaterally.  Flare-up of her condition was 9/10 in intensity.  She stated she can walk 1 mile before limping and back aggravation setting in and she also would no longer have control of her right leg.  Physical examination showed her gait slightly favored of the right leg.  Lumbar flexion was 85 degrees (90 normal) with stated pain to both sacroiliac joints.  Extension was 45 degrees (45 normal) with stated strain.  Right rotation was 25 degrees (normal 30) with stated pressure.  Left rotation was 40 degrees (30 normal) without pain. Lateral bending bilaterally was 45 degrees (30 normal) without pain.  The CI had lower lumbar spine TTP with bilateral SIJ TTP and right sciatic notch TTP.  Her spine was straight. No spasm was noted.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back and right side pelvic pain condition 10%, coded 5236 (sacroiliac injury and weakness), citing spasms.  The VA rated the low back and right side pelvic pain condition 0% coded 5236 (sacroiliac injury and weakness), based on the VA C&P examination 4 months after separation, citing  limitation of forward flexion and combined range of motion.  

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/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the VA examination.  There was muscle spasm with an abnormal gait noted at the pre-separation MEB NARSUM examination, but at the post-separation VA examination 4 months after separation, there was no muscle spasm noted.  The Board found this was consistent with post-separation improvement of the CI’s stress induced SIJ inflammation, noted to be improving on a restrictive profile, which would be anticipated to improve further when the CI was no longer subjected to the rigors of military lifestyle.  At the VA examination the CI reported having been hospitalized five times in the past year, but there was no corroboration of this in the record.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes of total duration of at least two weeks for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  The Board’s rating recommendation includes both the low back pain and sacroiliac dysfunction IAW VASRD §4.66 (sacroiliac joint) which stipulates “The lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes.”  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 and right side pelvic pain condition.  

BOARD FINDINGS:  In the matter of the low back and right side pelvic pain 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 20150530, 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

07 Feb 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160019834 (PD201500398)

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