RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00710
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041025

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Telecommunications Operator, medically separated for “sacroiliac joint dysfunction” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention.  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 - 20040614	VARD - 20050321	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Sacroiliac Joint Dysfunction, with Low Back Pain, Hip Pain, Right Greater than Left.	5236	0%	Lumbosacral Herniated Nucleolus Pulposus at L5-S1 and Lumbosacral Strain-Myositis.	5236-5243	20%	20050224	
			Right Hip Trochanteric and Ischial Bursitis; Claimed as "Hip"	5019-5252	10%	20050224	
	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Sacroiliac Joint Dysfunction, with Low Back Pain (LBP), Hip Pain, Right Greater than Left.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed right hip pain in 2001.  The onset was recorded following a “butterfly stretch” and falling on her right knee during a PT drill.  On 13 December 2001 bone scan studies were normal.  On January 2002, X-rays of the right hip were also normal. The CI was referred to physical therapy (PT), but her pain persisted.  On 23 September 2002, orthopedics evaluation thought the CI had a greater trochanteric bursitis (inflammation of a bursa [a gel filled sac to reduce friction] near the hip).  Despite treatment with medications, duty restrictions, and PT, the right hip pain persisted and progressed.  On 16 December 2002, neurosurgery noted normal range of motion (ROM) of the back and a normal neurological examination.  Magnetic resonance imaging (MRI) showed mild degenerative disc disease (DDD) from L2-5, but without a herniated disc (HNP).  X-rays were normal.  At that time it was thought that her pain might be related to sacroiliac joint (SIJ) dysfunction, the joint between the lower spine and the pelvis, and she was referred for an injection.  On 23 September 2003, neurosurgery examination showed a normal motor and sensory examination.  The injections provided partial relief, but it was not sufficient for return to full duty and she was then referred for MEB.  

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 1 October 2003, 13 months prior to separation, the CI reported ongoing low back pain (LBP).  On examination, she was noted to have tenderness over the lumbar muscles.  Provocative testing for nerve root irritation was positive on the right.  In physical therapy on 24 November 2003, the lumbar active range of motion (ROM) was normal.  The panel observed that there had been multiple clinical notes in 2002 and 2003 which documented a normal ROM.  On 30 April 2004, formal ROM measurements in physical therapy for the MEB showed forward flexion of 35 degrees (normal 90) and a combined ROM (after rounding) of 150 degrees (normal 240).  

The neurosurgery addendum to the MEB NARSUM examination was performed on 13 May 2004, 5 months prior to separation, noted a 3-year history of LBP and right SIJ pain aggravated by activity.  She reported that she was taking no medications (prescribed or over the counter) although her pain level was 8-9/10.  On examination, she was noted to have a normal neurological examination.  The ROM was near normal with flexion of over 85 degrees and a combined ROM of 215 degrees with both rotation and lateral bending exceeding VA normal values bilaterally.  The panel observed that there were two handwritten notes by neurosurgery the same day one of which had identical measurements and the other, written 2 hours earlier, noted flexion limited to 40 degrees bending with 25 degrees extension.  It was noted that “flex/ext” were without abnormal motion.  The panel assigned higher probative value to the NARSUM addendum values as these matched one handwritten note, done by the neurosurgeon, and the other noted recorded that there was no abnormal motion.  It was also noted by the neurosurgeon who prepared the addendum that there was some degree of embellishment (on the part of the CI).  

At the VA Compensation and Pension (C&P) evaluation performed on 24 February 2005, 4 months after separation, the CI reported constant pain that limited walking to 10 minutes.  She did not use an assistive device.  The thoracolumbar ROM showed painful motion with flexion of 60 degrees and a combined ROM of 160 (it is unclear if the combined ROM is 160 or 180, but this had no bearing on the rating recommendation).  Hip flexion and extension were normal.  There was a slight reduction in external rotation, abduction (leg out), and adduction (cross legs).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “sacroiliac joint dysfunction, with low back pain, hip pain, right greater than left” condition 0%, coded 5236 (sacroiliac injury and weakness) noting a normal neurological examination and full ROM.  The VA rated the CI for both LBP and for right trochanteric bursitis.  The lumbosacral herniated nucleus pulposus with lumbosacral strain at 20%, analogously coded 5236-5243 (sacroiliac injury and weakness and intervertebral disc syndrome) and the right hip trochanteric and ischial bursitis condition at 10% coded 5019-5252 (bursitis and thigh, limitation of flexion) based on the C&P examination 8 months after separation, citing the C&P examination 4 months after separation.  The panel first noted that the MEB forwarded SIJ dysfunction and the PEB determined this to be unfitting.  While trochanteric bursitis had been diagnosed during the evaluation, it was not considered by either the MEB or PEB.  As noted by the PEB, SIJ dysfunction is considered under the VASRD spine rules and coded 5236.  The PT, one neurosurgery measurement, and the VA C&P ROM measurements supported a 20% rating for limitation in motion.  However, the PEB neurosurgery NARSUM addendum measurements, which supported a 10% rating, were consistent with multiple previous ROM measurements prior to separation and was therefore assigned a higher probative value by the panel majority for rating purposes at separation.  The panel also noted that the measurements which supported the 20% rating followed the informal PEB and appeal by the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the SIJ dysfunction condition, coded 5236.  

BOARD FINDINGS:  In the matter of the sacroiliac joint dysfunction condition, the panel majority recommends a disability rating of 10%, coded 5236 IAW VASRD §4.71a.  The single voter for dissent recommended modification to 20% and did not elect to submit a minority opinion.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Sacroiliac Joint Dysfunction 	5236	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160913, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015820, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

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

Sincerely,	
Enclosure