RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01792
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Intelligence Analyst, medically separated for “snapping hip syndrome evaluated as sacroiliac joint (SI) injury,” with a disability rating of 20%.  

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 condition(s) at the time of separation.  The panel 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 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 - 20080709	VARD - 20141029	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Snapping Hip Syndrome Evaluated as SIJ Injury	5299-5236	20%	Snapping Hip Syndrome, Right Extension	5251	0%	20141029	
			Snapping Hip Syndrome, Left Extension	5251	0%	20141029	
			Snapping Hip Syndrome, Right Flexion	5251	0%	20141029	
			Snapping Hip Syndrome, Left Extension	5251	0%	20141029	
Lumbago	Not Unfitting	Lumbago	5237	NSC	20141029	
Anxiety	Not Unfitting	Anxiety	9413	NSC	20141029	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Snapping Hip Syndrome Evaluated as SIJ Injury.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral hip and SI joint condition began in July 2007 during physical training.  At the 5 May 2008 Physical Medicine and Rehabilitation examination, 5 months prior to separation, the CI reported back pain and leg symptoms (bilateral snapping hips right greater than left), including right leg motor disturbance, numbness, and falls.  Physical examination showed gait and stance was abnormal with a limp.  There was tenderness to the bilateral SI joints with muscle spasm of the lower back.  There was painful motion of the thoracolumbar spine with lumbosacral spasm and painful motion.  The pelvis was abnormal with the right SIJ lower than the left.  The hips demonstrated snapping bilaterally with a positive piriformis test bilaterally (pain with hip flexion, abduction and internal rotation).  There was no decreased sensation or muscle weakness observed, and electrodiagnostic testing (EMG/NCV) of the right leg was negative for lower neuropathy.  Diagnostic imaging included an MRI in March 2008 showed hips with mild increased left iliopsoas signal and right subchondral acetabulum signal that ‘may be related to snapping hip syndrome;” normal hip X-rays and bone scan in April 2008; and normal lumbosacral X-ray in May 2008 (with prior X-ray in September 2006 having shown degeneration).  

There was no surgical indication.  Despite treatment, the CI’s 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 “snapping hip syndrome, right and left” as not meeting retention standards, as well as “lumbago” as meeting standards, for PEB adjudication.  

At the 2 June 2008 MEB examination (recorded on DD Forms 2807 and 2808), 4 months prior to separation, the CI reported chronic joint pain in lower back and extremities, numbness and tingling down legs to feet, snapping hip syndrome and SI dysfunction.  Physical examination showed “tenderness at ROMs in bilateral hips (and) tenderness at L4-S1.”  Diagnoses were SI dysfunction and snapping hip syndrome.  

The 17 June 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of right and left hip pain and “lower back pain and bilateral SIJ discomfort.”  Physical examination showed an abnormal gait.  The left and right hips each had painful and limited range of motion (ROM) as summarized in the chart below.  Pain radiated into the SI joints and to the inner thigh of each side.  There was an audible “clicking” noise with all hip ROM.  There was no lower extremity muscle atrophy and neurovascular status was intact.  Thoracolumbar ROM was flexion of 90 degrees (normal) and combined ROM of 225 degrees (normal 240) with “pain at both SIJ and both medial aspects of thighs” on all planes of motion.  There were non-physiologic signs of:  “superficial tenderness diffuse and skin discomfort on light palpation; significant pain with pressure throughout lower back musculature and in lower lumbar and sacral areas; axial loading - pain was elicited when pressing down on the top of the patient's head in her lower back causing her legs to bend.”  Spinal contour was normal.  There was no VA Compensation and Pension (C&P) evaluation in evidence proximate to separation.  The closest C&P examination in evidence was conducted on 2 September 2014, 6 years after separation.  

The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Hips (Thighs) ROM
(Degrees)	PT ~7 Mo. Pre-Sep	MEB ~4 Mo. Pre-Sep	
	Right	Left	Right	Left	
Flexion (125 Normal)	120	110	85	85	
Extension (20)	-	-	15	15	
External Rotation (45)	35	27	30	35	
Abduction (0-45)	“WNL”	“WNL”	45	45	
Adduction (45)	-	-	20	20	
Comment	Painful motion	Painful motion	Painful motion	Painful motion	
§4.71a Rating	10%	10%	10%	10%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left hip conditions and SI joint dysfunction as a single unfitting condition coded 5299-5236 (analogous to sacroiliac injury and weakness), and rated 20%, citing “abnormal gait with pain at the SI joint during ROM of the hips or thoracolumbar spine.”  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 panel’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 panel 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 panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

In this case, both hips and SI joint dysfunction were profiled and mentioned in the PEB disability description.  The right and left snapping hips were considered to fail retention standards, and general use of pain medication was implicated in the commander’s statement.  The STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either the left hip, the right hip, or the SI joints over the other.  Since undue speculation would be required to conclude that the left hip or right hip or SI joints’ impairment would not have unacceptably interfered with MOS performance, members agreed that each hip and the SI joints were reasonably justified as separately unfitting.  

With regards to rating the left and right hip conditions, all examinations in evidence documented sufficient evidence of painful motion of each hip with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each hip.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion, extension, or thigh impairment for greater than a 10% rating (codes 5251, 5252, or 5253).  There was no fracture of the femur for rating analogous to code 5255 (femur, impairment).  Since snapping hip syndrome is closest to a tendonitis recommended coding is 5099-5024 (tenosynovitis) for each hip.  

With regards to rating the SI dysfunction, the panel considered the tenants of VASRD §4.66 (sacroiliac joint) as well as §4.14 (avoidance of pyramiding) with a review of the diagnoses, exams, and pathology in evidence.  The SI joint condition is rated under the general formula for the spine code 5236 (analogous to sacroiliac injury and weakness).  All examination proximate to separation showed painful motion of the back with pain in both SI joints and the NARSUM examination showed limited thoracolumbar spine motion supporting a 10% rating under code 5299-5236.  Examinations also documented an abnormal gait and the board considered if the CI’s limping gait indicated spine “muscle spasm or guarding severe enough to result in an abnormal gait,” (20% criteria) or was attributed to, and part of the rating for the unfitting left hip and right hip conditions.  The panel adjudged that the abnormal gait was clearly attributable to the hip conditions and that the SI joint condition did not warrant the higher 20% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends an unfitting right hip condition rated 10% and coded 5099-5024, an unfitting left hip condition rated 10% and coded 5099-5024, and an unfitting SI dysfunction rated 10% and coded 5299-5236.  

Contended PEB Conditions:  Lumbago and Anxiety.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The rating above, under code 5236 (sacroiliac injury and weakness), encompasses any disability from the not unfitting lumbago condition IAW the VASRD and the general spine formula, so no separate rating or fitness determination for lumbago is warranted.  “Anxiety” was not profiled (S1), implicated in the commander’s statement, or judged to fail retention standards.  There was no performance-based evidence from the record that the anxiety condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended anxiety condition and so no additional disability ratings are recommended.  
BOARD FINDINGS:  In the matter of the snapping hip syndrome (bilateral) evaluated as SIJ injury condition, the panel unanimously recommends that each joint be separately adjudicated as follows: an unfitting right hip condition coded 5099-5024 and rated 10%, an unfitting left hip condition coded 5099-5024 and rated 10%, and an unfitting SI joint condition coded 5299-5236 and rated 10%, all IAW VASRD §4.71a.  In the matter of the contended anxiety and lumbago conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Snapping Hip Syndrome Right	5099-5024	10%	
Snapping Hip Syndrome Left	5099-5024	10%	
SI Injury	5299-5236	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150630, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009080, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure