RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01678
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040519

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Advanced Individual Trainee, medically separated for “chronic low back pain” and “chronic right hip pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  Current condition supports a higher rating.  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 - 20040415	VARD - 20050119	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Chronic Lumbar Strain	5237	10%	20040920	
Chronic Right Hip Pain	5099-5003	0%	Chronic Right Hip Sprain	5252	0%	20040920	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in June 2003 when she fell from the obstacle course during basic training and landed on her right hip.  She continued to train with a severe limp and developed back pain.  X-rays of the lumbosacral spine dated 24 June 2003 were normal, while a bone scan on 25 September 2003 revealed normal soft tissue and bone activity throughout the pelvis, hips, and proximal femurs.  An MRI dated 14 October 2003 demonstrated a mild symmetric disc bulge at L4-5 with mild lateral recess stenosis.  There was some narrowing on the lateral recesses bilaterally.  Lumbar spine X-rays in December 2003 demonstrated normal bone mineralization and alignment with no fractures identified.  The intervertebral disc height appeared well-maintained and the visualized soft tissues were unremarkable.  At a 9 December 2003 clinic visit the CI reported that surgery was not recommended by a neurosurgeon she had recently seen.  On examination the CI had “full” range of motion (ROM) with flexion limited secondary to pain and tenderness of the lower lumbar area.  Straight leg raising for radiculopathy was negative.  At a physical therapy (PT) visit on 16 December 2003, lumbar flexion was fingertips to the knees (approximately 45-60 degrees; normal 90) with painful motion and right hip pain.  At a follow-up PT visit on 6 January 2004, lumbar flexion was fingertips to the distal shins (approximately 70-80 degrees) with pain.  PT was discontinued since the CI could not tolerate it and had no improvement.

During the 21 January 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported constant back pain and the inability to stand for too long or bend.  Physical examination showed a “full” ROM with spinal tenderness and muscle spasm.  Straight leg raising was negative.  The 15 March 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of worsening lower back and hip pain with any significant activities including working, prolonged standing, running, bending, and twisting.  Physical examination showed an antalgic gait, although she was able to heel-toe walk without difficulty.  There was spinal tenderness and muscle spasms.  Straight leg raising was negative.  Motor strength in the lower extremities bilaterally was 5/5.  Sensation and reflexes were normal.  Lumbar flexion was fingertips to the proximal shins (approximately 65-80 degrees); combined ROM was incomplete but painful motion was present.  The 16 March 2004 MEB PT examination, 2 months before separation, noted complaints of low back and right hip pain.  Repetitive ROM was flexion to 60 degrees and the combined ROM was 195 degrees; painful motion was not addressed.

At the 20 September 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported constant LBP and stiffness.  Physical examination showed a normal spinal contour with spinal tenderness present but no muscle spasm.  Straight leg raising and motor strength testing were negative.  Spinal flexion was 90 degrees and combined ROM was 240 degrees; painful motion was not addressed.  Lumbar spine X-rays showed lumbar vertebrae with no additional abnormalities, and all disk spaces were intact.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5237 (lumbosacral strain), citing ROM limited by pain.  The VA also rated the LBP condition 10%, coded 5237, based on the C&P examination 4 months after separation, citing limitation of motion.  The panel majority agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees).  The panel majority noted only one of six STR ROM examinations was quantified, rendering less probative value to those five examinations.  The panel majority determined the MEB PT examination had the highest probative value as it documented repetitive flexion to 60 degrees and was most proximate (2 months) to separation.  The VA examination, 4 months after separation, supported a 10% rating based on full flexion to 90 degrees but with painful motion. There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the chronic LBP condition, coded 5237.

Chronic Right Hip Pain.  According to the STR and the MEB NARSUM, the CI’s right hip condition began in June 2003 after a fall from the obstacle course during basic training.  A 24 June 2003 orthopedic visit noted an antalgic gait and right hip pain with all motions.  X-rays were normal.  The CI was assessed with a right hip contusion and treated with PT and non-steroidal anti-inflammatory drugs.  An August 2003 MRI showed normal hips and pelvis.  A 25 September 2003 bone scan ruled out a right hip stress fracture, showing normal soft tissue and bone activity throughout the pelvis, hips, and proximal femurs.  During a 16 December 2003 PT visit the CI complained of constant right hip pain which increased with walking, prolonged sitting and standing, and cold weather.  Physical examination revealed right hip tenderness and the FABER test (to reproduce hip pain) was more positive on the right than the left.

During the 21 January 2004 MEB examination, 4 months prior to separation, the CI reported constant right hip pain.  Physical examination showed “full” right hip ROM with tenderness at extreme internal/external rotation.  X-rays of the right hip dated 19 February 2004 were normal.  The 15 March 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of worsening lower back and hip pain with any significant activities.  Physical examination showed an antalgic gait.  There was right hip tenderness.  ROM was “full” for the bilateral hips, knees, and ankles.  The right hip elicited painful motion.  The 16 March 2004 MEB PT examination noted complaints of right hip pain.  Physical examination showed repetitive ROM of flexion to 110 degrees (normal 125), extension 15 degrees (normal 20), external rotation 45 degrees (normal 45) , abduction 45 degrees (normal 45), and adduction 15 degrees (normal 45); painful motion was not addressed.

At the 20 September 2004 VA C&P evaluation, 4 months after separation, the CI reported constant right hip pain.  Physical examination showed a mild limp at the right lower extremity.  There was significant bilateral hip tenderness.  Bilateral flexion was 0-120 degrees, extension 30 degrees, abduction 45 degrees, and adduction 30 degrees with over 45 degrees of external rotation and 30 degrees of internal rotation; painful motion was elicited.  Mild weakness was associated with pain.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right hip condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing normal ROM.  The VA also rated the right hip condition 0%, coded 5252 (thigh, limitation of flexion), based on the C&P examination 4 months after separation, citing non-compensable limitation of motion.  The panel agreed there was no compensable ROM (codes 5251, 5252, and 5253), hip ankylosis (code 5250), hip flail joint (code 5254), or femur impairment (code 5255) to support a 10% rating.  However, there was evidence of painful motion with functional loss documented on the MEB NARSUM and VA examinations to support a 10% rating IAW VASRD §4.59, §4.40, §4.45, (painful motion, functional loss and the joints).  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 chronic right hip pain condition, coded 5099-5003.

BOARD FINDINGS:  In the matter of the chronic LBP condition, the panel majority recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  In the matter of the chronic right hip pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows; and, 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	
Chronic Low Back Pain 	5237	20%	
Chronic Right Hip Pain	5099-5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161101, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Minority Opinion for PD-2016-01678

Minority Opinion:  The panel minority concurs with the majority that there was satisfactory evidence of painful motion to warrant a modification of the rating of the right hip from 0% to 10%.  However, the minority non-concurs with the majority in regards to rating the thoracolumbar spine at 20%.  The STR contained six ROM examinations that ranged from 5 months prior to separation to 4 months after separation.  Two of the six ROM examinations supported a rating of 20%, but neither of the flexion measurements of those ROM examinations were conducted with the required goniometer, which is the only measuring device that is VASRD compliant.  The other four ROM examinations supported either a 0% or 10% rating for ROM limitation, but only one of those examinations was conducted with the required goniometer and that was the VA C&P examination conducted 4 months after separation.  In assessing the probative value of these conflicting examinations, the minority assigned more probative value to the VA C&P examination because it was the only examination proximate to separation that contained ROM measurements that were VASRD compliant.  Although the CI experienced pain at 45 degrees of flexion with ROM testing during the VA C&P ROM study, she was able to fully flex her thoracolumbar spine.  The minority also noted that the CI’s total combined thoracolumbar ROM was 240 degrees (normal), but there were complaints of pain with rotation movements.  Although there was no limitation of thoracolumbar spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine, the C&P examination showed the presence of painful motion.  A 10% rating was therefore warranted.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel minority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  The panel minority 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	
Chronic Low Back Pain	5237	10%	
Chronic Right Hip Pain	5099-5003	10%	
COMBINED	20%	

AR20180002571, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,					      
Enclosure