RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00774
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060406

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Military Intelligence Systems Maintainer/Integrator, medically separated for bilateral sacroiliac joint pain, with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention.  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 on 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 -20051228	VARD - 20060929	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Sacroiliac (SI) Joint Pain…	5236	10%	Strain of Both Sacroiliac Joints	5236	20%	20060717	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Sacroiliac Joint Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral sacroiliac joint pain and dysfunction began following the delivery of her son in September 2001.  X-rays on 14 January 2003, ordered for a 4 month history of pain in the right hip demonstrated minor chronic changes involving the inferior aspects of the symphysis pubis; however, the hip joints were within normal limits without any fracture or dislocation or evidence to suggest avascular necrosis.  X-ray studies on January 2003 showed no findings that showed fusion or erosion of either sacroiliac joint and no hypertrophic bony changes were identified.  The impression the sacroiliac joints were within normal limits.  A note in March 2005 indicated the CI had pain located in the sacroiliac area, which was treated with a course of physical therapy and chiropractic treatment along with multiple medications, which provided some temporary relief.  A pain management consultation in April 2005 revealed palpation and percussion of the thoracic and lumbar spine including the sacrum were painless.  There were bilaterally negative slump maneuvers (to determine a herniated disc) and negative straight leg raises (to determine nerve root irritation).  Bilateral Patrick’s/FABER tests (to determine hip pathology) were negative.  Pelvic provocative testing was positive for exact reproduction of her pelvic pain as with hip flexion and contralateral hip extension. She was exquisitely tender over the bilateral sacroiliac joints and bilateral greater trochanters.  Neurologic evaluation was unremarkable and she was able to stand on her toes and heels and perform a symmetric deep knee bend.  The CI was able to rise from a chair with a fluid motion and to walk normally. She was recommended to obtain an SI-Loc belt to stabilize the SI joints, to undergo a series of steroid injections, and to take Arthrotec (diclofenac, a nonsteroidal anti-inflammatory drug (NSAID)) and misoprostol (to decrease gastric irritation).  However, the injections did not provide relief and she did not try the Arthrotec.  She received no surgical recommendation.  

Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “bilateral SI joint pain and dysfunction, left greater than right” for PEB adjudication.  

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 5 December 2005, 5 months prior to separation, the CI reported she had joint problems and wore an SI Loc belt.  Physical examination ROM measurements are in the chart below.  The MEB NARSUM examination on 5 December 2005, 4 months prior to separation, noted complaints of constant and daily bilateral SI joint pain that spread to the front and down to the knees. The pain increased with walking, sitting, standing, running, direct trauma, unusual movements, and exercise with an occasional sudden increased pain, which will caused her legs to give out.  On examination, there was a normal gait with tenderness of the back and pain with motion.  Straight leg raise testing produced radiating pain in both legs.  Thoracolumbar ROM after repetition was normal.  

At the 17 July 2006 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported pain that radiated to the upper lumbar paraspinal area and sometimes and went into either leg, either on the back or the front of either thigh to the knee joint level, but never in both legs at once.  Pain was aggravated by standing stooping and twisting.  
On examination, there was a normal gait, pain with motion, and no muscle spasm in the lumbosacral area severe enough to result in an abnormal gait or an abnormal spinal contour (reverse lordosis or scoliosis).  However, there was pain was in both sacroiliac joints.  ROM measurements are in the chart below.  With repetition, the pain increased, and she lost an additional 11 degrees of flexion and 10 degrees of extension. Straight leg raising was positive in each lower limb with pain in the back.  She had pain in both greater trochanter bursae, but no pain with internal rotation of the hips.  X-rays revealed no significant abnormality of the lumbar spine and no significant abnormality was identified of the pelvis and bilateral hips.  The CI was to forward a copy of the magnetic resonance imaging (MRI) in 2003 of the lumbar spine, pelvis, and hips, which showed some kind of gap in her hip joints.   

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)	MEB ~4 Mos. Pre-Sep
	VA ~3 Mos. Post-Sep
	
Flexion (90 Normal)	90 (90, 100, 95)	45(44)	
Extension (30)	25 (25, 30, 25)	20	
R Lat Flex (30)	30 (35, 40, 40) 	15	
L Lat Flex (30)	30 (30, 30, 30)	25 (24)	
R Rotation (30)	30 (65, 65, 60)	30	
L Rotation (30)	30 (65, 70, 70)	30	
Combined (240)	235	165	
Comments	Pain at the extremes; normal gait; tenderness at the SI joints	Painful motion; with repetition, she lost 11 degrees of flexion (35), and 10 degrees of extension 	
§4.71a Rating	10%	20%	

Hip (Thigh) ROM
(Degrees)	MEB ~4 Mos. Pre-Sep
	VA ~3 Mos. Post-Sep
	
	Left	Right	Left	Right	
Flexion (125 Normal)	90	90	97	102	
Extension (20)					
External Rotation (45)	40	45	60	60	
Abduction (0-45)	40	45	45	45	
Adduction (45)	30	35	20	20	
Comment	Bent knee flexion: 100, 110, pain	SI joint pain with flexion, adduction, and external rotation more than internal rotation; pain with repetition; no loss of motion	Pain on flexion and straightening and then felt in the 
Si joint area; SI joint pain with adduction and more with external rotation than with internal rotation; pain with repetition; no loss of motion	
§4.71a Rating	-	-	-	-	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for the sacroiliac joint condition under the 5236 code (Sacroiliac injury and weakness), citing full but painful range of motion, without spasm or radiculopathy, but with tenderness to palpation in the sacrum and sacroiliac joints.  The VA assigned a 20% rating using the 5236 code, based on the VA C&P examination 3 months after separation, citing flexion of 44 degrees and extension to 20 degrees, with pain during range of motion testing.  Additionally, the VA assigned a 10% rating for bursitis of the greater trochanter bursa, left and a 10% rating for bursitis of the greater trochanter, right under the 5252 code (Thigh, limitation of flexion of:); however, the hips were not in the scope of review since neither condition was referred by the MEB nor adjudicated by the PEB IAW DoDI 6440.44.  Furthermore, although the VA rated the conditions independently, pyramiding IAW VASRD §4.14 is to be avoided since the sacroiliac pain addressed the CI’s functional limitations IAW with VASRD §4.66 and there was no significant pathology of the hips prior to separation to support either unfitness or an independent rating for the hip pain.  Members agreed that the MEB examination was more consistent and thorough, and more reflective of the anticipated severity based on the clinical pathology.  Therefore, the Board relied more heavily on the MEB measurements, and although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of painful motion and tenderness.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  Board members also noted that the significant drop in the flexion ROM at the VA examination was without explanation in the STR with no reference to an accident, injury, or surgery.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had a positive straight leg raise test, and symptoms of leg pain and numbness documented in the treatment records; however, examinations indicated normal strength, reflexes and gait, and the sensory changes did not affect her job.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  Therefore, Board concluded that an additional disability 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 joint condition.  

BOARD FINDINGS:  In the matter of the sacroiliac joint 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 20150603, 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 XXXXXXXXXXXXXXXXXXXXX, AR20170000947 (PD201500774)

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