RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02227
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080711

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, trainee, medically separated for “lumbosacral strain” and “bilateral hip pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI contends her hips and back.  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 - 20080307	VARD - 20090107	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Low Back Arthralgia/DDD	5242	0%	20080902	
Bilateral Hip Pain	5099-5024	0%	Left Hip Arthralgia and Tendonitis	5024	0%		
			Right Hip Arthralgia and Tendonitis	5024	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lumbosacral strain began in November 2006 after ruck marching and physical training.  The CI denied any direct trauma.  Conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic low back pain” for PEB adjudication.  At the 26 November 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported low back pain with associated intermittent feet and leg numbness.  Physical examination showed mild lower lumbar region tenderness to palpation without paravertebral muscle spasms.  Straight-leg raises were negative bilaterally at 90 degrees.  The 30 November 2007 MEB NARSUM examination, 7 months prior to separation, noted complaints of chronic low back pain since 2006.  Physical examination of the thoracolumbar spine showed decreased range of motion in the left lateral side with mild tenderness to palpation over the lower lumbar region without paravertebral spasm.  Straight-leg raises were negative bilaterally at 90 degrees.  Heel-toe was walking was performed without difficulty.  The thoracolumbar range of motion (ROM) was full in all planes except left side bending at 20 degrees (normal 30) due to pain.  MRI of the back showed some disc bulging and protrusion at L4-5.  

At the 2 September 2008 VA Compensation and Pension (C&P) general medical evaluation, performed 2 months after separation, the CI reported intermittent non-radiating low back pain lasting less than an hour with maximum pain level of 1-2/10 and no incapacitating episodes within the previous year.  Physical examination showed ROM of the lumbar spine shows active flexion to 90 degrees (normal 90) without pain, active extension to 30 degrees (normal 30) without pain, active rotation to 30 degrees (normal) bilaterally without pain, active lateral flexion to 30 degrees (normal) bilaterally with pain in the left hip once she laterally flexed to 30 degrees on the right.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the lumbosacral strain condition 10%, coded 5237 (lumbosacral strain), citing full motion with some localized tenderness.  The VA also rated the lumbosacral strain condition 0% coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 2 months after separation, citing a normal flexion of 90 degrees and normal combined motion of 240 degrees and the absence of muscle spasm, localized tenderness, or guarding.  

The panel placed greater probative value on the C&P evaluation as the best indication of the CI’s back ROM at time of separation.  The panel agreed that there was no limitation of forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height to justify a rating of 10%.  The panel also considered if an additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  There was no associated radiculopathy for separate peripheral nerve rating.  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.  The panel concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the lumbosacral strain condition.  

Bilateral Hip Pain.  The PEB combined the bilateral hip pain conditions as a single unfitting condition analogously coded 5099-5024 (Tenosynovitis) and rated 0%.  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.  The evidence for the bilateral hip pain conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to STR and the MEB NARSUM, the CI’s bilateral hip pain began in November 2006 after ruck marching and physical training.  The CI denied any specific direct trauma.  Conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral hip tendonitis” for PEB adjudication.  At the 26 November 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported bilateral hip pain with associated intermittent feet and leg numbness made worse with prolonged sitting or standing.  Physical examination showed Decreased ROM of both hips.  Tenderness to palpation over the right iliac crest.  Toe out bilaterally greater than 15 degrees and able to cross legs bilaterally.  At the 27 November 2007 Physical Therapy examination, 7 months prior to separation, the CI reported bilateral hip pain.  Physical examination showed full active ROM of both hips.  At the 28 November 2007 Orthopedic examination, 7 months prior to separation, the CI reported bilateral hip pain.  Physical examination showed an antalgic gait with tenderness anteriorly as well as the sacroiliac joint, right hip and into the groin.  The left hip revealed tenderness anteriorly and into the groin as well but there was no tenderness over the left sacroiliac joint.  There was no tenderness of either greater trochanter.  There was full painless range of motion in both hips with tight quads bilaterally.  There was no pain with straight-leg raises.  There was no pain with internal or external rotation or with axial loading of the hips.  There was no impingement sign of the hips.  The rest of the physical examination was within normal limits.  The 30 November 2007 MEB NARSUM examination, 7 months prior to separation, noted complaints of bilateral hip pain that radiates into the groin area.  Her symptoms are constant and vary from an annoying ache to a sharp, stabbing sensation rated 2 to 10/10 and worse with prolonged sitting, standing, walking, climbing stairs and bearing weight.  Physical examination of the bilateral hips showed minimally decreased range of motion in external rotation with tenderness over the right groin and iliac crest.   The CI was able to toe out bilaterally greater than 15 degrees and cross over bilaterally with minimal discomfort.  

At the 2 September 2008 VA C&P evaluation, performed 2 months after separation, the CI reported chronic hip pain which averages 3-4/10 with flare-ups to 8/10 occurring 2 to 3 times a week lasting from four hours to all day.  Physical examination of the hips showed an active flexion to 125 degrees (normal 125) bilaterally, active extension to 30 degrees (normal 20) bilaterally, active adduction to 25 degrees (normal 45) bilaterally, active abduction to 45 degrees (normal 45) bilaterally, active external rotation to 60 degrees (normal 45) bilaterally, active internal rotation to 40 degrees bilaterally and all without pain.  

The panel first considered if the bilateral hip pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both hips were cited in the commander’s letter dated 17 December 2007 as significantly contributing to her inability to perform her full duty.  Panel members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties and accordingly a separate disability rating is recommended.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the bilateral hip pain condition and applied a single 0% rating, analogously coded 5099-5024 (Tenosynovitis), citing.  The VA rated the right hip condition 0% coded 5024 (Tenosynovitis), based on the VA C&P examination 2 months after separation, citing full and painless range of motion at the joint.  The VA also rated the left hip condition 0% coded 5024 (Tenosynovitis), based on the VA C&P examination 2 months after separation, citing full and painless range of motion at the joint.  For both hips there was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5251 or 5252).  There was no limitation of abduction or adduction or rotation that supported a rating under the VASRD diagnostic codes for limitation of motion (5253).  There was no hip flail joint that supported a rating under the VASRD diagnostic code (5254).  There was no evidence of painful motion on any exam of the hips with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45).  As the individual right and left hip ratings do increase the PEB’s bilateral hip rating, there is no benefit to the CI to rate each hip individually.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral hip conditions.  

BOARD FINDINGS:  In the matter of the lumbosacral strain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral hip pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, 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 , w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012149, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,