RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01462
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20021031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty  E5, Special Intelligence Communication, medically separated for “mechanical low back pain” with a disability rating of 0%.   

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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 conditions at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The panel 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 - 20020820	VARD - 20030707	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Low Back Pain	5295	0%	Mechanical Low Back Pain	5295	10%	20030311	
Left Hip Bursitis	CAT II	Left Hip Bursitis	5019	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Mechanical Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mechanical low back pain began in approximately 2006 during a 2 week period of intense marching with full combat gear.  At a family practice clinic visit on 14 November 2001 the CI had tenderness to palpation over the S1-S2 and sacroiliac (SI) joints and no radicular symptoms.  Treatment consisted of Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)) and Robaxin (methocarbamol, a muscle relaxer).  At a physical therapy clinic appointment on 8 January 2002, 10 months prior to separation, the CI reported no specific injury but recalled gradually worsening of pain with symptoms exacerbated during her pregnancy.  The CI complained of pain on the lower back and left groin without radicular pain.  Physical examination showed a normal gait.  The range of motion (ROM) of the lumbar spine was within normal limits and pain free in all ranges.  There was normal strength in the lower extremities, a positive Stork test (to assess the sacroiliac joint), positive sacral compression, and tenderness to palpation of the left sacral sulcus and SI joint. Straight leg raise test was negative for radiculopathy; the Slump test (to determine neural sensitivity) was negative; the FABER test (to determine hip pathology) was positive on the left; and reflexes were normal.  There was a 2.0 centimeter leg length disparity on the left with anterior rotation, but equal length after bridging and long axis distraction.  The examiner diagnosed a possible left SI dysfunction.  At a physical therapy follow-up appointment on 11 February 2003, physical examination showed a normal gait; ROM measurements were within normal limits for the lumbar spine and were pain free; and the left hip ROM measurements were within normal limits with pain.  At a neurosurgery clinic appointment on 7 March 2002, 8 months prior to separation, the examiner noted the CI had been to physical therapy and two epidural steroid injections with only several hours of improvement.  The CI reported pain was in the left anterior superior iliac spine (ASIS) area and the left SI area and physical examination showed tenderness over those areas.  Straight leg raise testing and FABER testing were negative and there was normal strength in the lower extremities.  At an orthopedic evaluation on 22 April 2002 to determine the coexistence of any primary hip pathology the CI had internal and external rotation without pain and a hip full ROM equal to the contralateral hip.  FABER testing was positive, but there were no hip clicks; however, there was tenderness to palpation over the greater trochanter.  The examiner’s assessment was there was no primary hip pathology.  Greater trochanteric bursitis was considered to be secondary to gait modification and the SI joint appeared to be the primary area of pain.  The CI’s back and neurologic status were not evaluated.  Stretching for the iliotibial band/greater trochanter was recommended.  

The 13 May 2002 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic low back pain and left hip pain.   Physical examination showed full strength and sensation in both lower extremities; straight leg raise test was negative for radiculopathy; and there were no radicular symptoms.  Reflexes were 3+ bilaterally at the knees and ankles.  The CI had 4+/5 strength in left hip flexion but otherwise full strength in the left lower extremity.  Magnetic resonance imaging (MRI) and radiographic (X-ray) studies of the lumbar spine were reported to be normal.  During the 20 May 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported recurrent back pain.  Physical examination showed left sided paraspinal spasm and tenderness to palpation.

At the 11 March 2003 VA Compensation and Pension (C&P) evaluation, less than 5 months after separation, the CI reported a history of low back pain with diminished strength and ROM of the left hip.  Physical examination showed pain at the left SI joint with palpation and ROM; however, there were no quantitative measurements.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5295 (lumbosacral strain).   The Navy PEB also listed left hip bursitis as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The VA rated the back condition 10%, coded 5295, citing characteristic painful or limited motion and that a 20% was not warranted unless evidence demonstrated muscle spasm on extreme forward bending and unilateral loss of lateral spine motion in a standing position.  The VA additionally rated the left hip bursitis at 10% under code 5019 (bursitis), citing “for painful or limited motion of a major joint.”  

In accordance with DoDI 6040.44, the panel is required to recommend a rating IAW the VASRD in effect at the time of separation.  The panel noted that the 2002 VASRD standards for the spine including the interim spine rule related to code 5293 (intervertebral disc syndrome), which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The panel must correlate the above clinical data with the 2002 rating schedule and applicable diagnostic codes.  There was no vertebral fracture (5285), complete spine ankylosis (5286), dorsal spine ankylosis (5288), lumbar spine ankylosis (5289), limitation of dorsal spine motion (5291), or limitation of lumbar spine motion (5292) for consideration under the respective codes.  There was no neuropathy, characteristic pain, muscle spasm, absent deep tendon reflexes, neurological findings appropriate to disc site, or recurring attacks for consideration under intervertebral disc syndrome (5293).   Members discussed use of codes 5294 (sacroiliac injury/weakness) IAW VASRD §4.66 (sacroiliac joint) and 5295.  A 10% rating requires “characteristic pain on motion,” which was evident at the left SI joint during the Stork and compression tests and ROM at the VA examination 5 months post-separation; and, there was tenderness to palpation at the SI joint on several examinations.  While muscle spasm was reported, the STR did not address the requirements for a 20% rating that include “muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the mechanical low back pain condition, coded 5294-5295.  

Left Hip Bursitis.  The PEB listed the left hip bursitis condition as a category II condition, a condition that is related to the primary unfitting condition and contributes to the primary unfitting condition.  The panel’s first charge for this Navy PEB Category II condition is to assess whether it can be reasonably justified as separately unfitting for rating consideration.  The panel’s threshold for such determinations is reasonably unfitting and remains adherent to the DoDI 6040.44 “fair and equitable” standard.  A note dated 9 February 2000 indicated the CI had bilateral hip pain for 3 years.  A physical therapist assessed the condition as SI dysfunction with either a lowered left ASIS (anterior superior iliac spine) or an elevated right ASIS.  Treatment with physical therapy modalities was recommended.  An MRI of the hip on 27 June 2000 demonstrated no evidence of bony pathology.  On 11 February 2002 the left hip ROM was within normal limits with pain with overpressure towards the end of the motion.  The Limited Duty Medical Board Report dated 7 March 2002 noted chronic low back and left hip pain.  Orthopedic evaluation on 22 April 2002 noted X-rays of the hips were normal, but there was tenderness to palpation over the greater trochanter without warmth.  The examiner opined there was no primary hip pathology; however, greater trochanteric bursitis was most likely secondary to gait modification.  The Non-Medical Assessment (NMA) dated 18 May 2002 indicated the CI’s physical ailment hindered her ability to perform the MOS duties associated with her position.  However, the NMA specifically only referred to back pain although the hip condition likewise presumably contributed to her non-participation in physical fitness events, lifting equipment, or prolonged standing.  At a VA medical examination on 11 March 2003, less than 5 months after separation, the examiner noted a decreased ROM of the left hip with decreased hip flexion and external rotation secondary to pain. 

Members agreed that the subsumed Category II left hip bursitis condition was reasonably justified as separately unfitting since the long term presence of hip pain not responsive to treatment contributed to her inability to perform her duties.  Furthermore, there was no preponderance of evidence to determine the left hip was not unfitting.  While there was tenderness to palpation over the right hip, there was no evidence of limitation of motion or painful motion prior to separation; however, less than 5 months post-separation there was decreased hip flexion secondary to pain.  Members discussed that while the left hip condition was unfitting, painful motion emanated from the SI joint prior to separation, but there was no documented pain on motion until 5 months post-separation.  Nevertheless, since the anatomical relationship of the lower back and the hip overlapped in the area of the SI to rate the left hip condition independent of the lower back would invoke VASRD §4.14 (avoidance of pyramiding), which is to be avoided.  After due deliberation, the panel agreed that the evidence was reasonably unfitting with regard to the functional impairment of the left hip bursitis condition and favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5019 (bursitis) and meets the VASRD §4.71 criteria for a 0% rating.  

BOARD FINDINGS:  In the matter of the mechanical low back pain condition, the panel unanimously recommends a disability rating of 10%, coded 5294-5295 IAW VASRD §4.71a.  In the matter of the Category II left hip bursitis condition, the panel unanimously agrees that it was unfitting and recommends a disability rating of 0% or 10%, coded 5019 IAW VASRD §4.71a.

CONDITION	VASRD CODE	PERMANENT RATING	
Mechanical Low Back Pain	5294-5295	10%	
Left Hip Bursitis	5019	0% 	
COMBINED	10% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150619, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 06 Jul 17 XXXXXXXXXXXXXXXXXX  
	(d) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 31 Jul 17 XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 07 Jul 17 XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 02 Aug 17 XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 06 Jul 17 XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (h) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.      

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.   

     g. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.       
     
3.  Please take action to implement these decisions.

	XXXXXXXXXXXXXXXXXX
	Acting,