RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-00818
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20050509

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Military Police, medically separated for “chronic pain over the right sacroiliac and gluteal region” with a disability rating of 10%.   

CI CONTENTION:  “Should be considered for military retirement.  I have had severe PTSD...”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20050309	VARD - 20070521	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Over the Right Sacroiliac and Gluteal Region…	5236	10%	Lumbar Strain	5237	0%	20070312	
	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Pain over the Right Sacroiliac and Gluteal Region.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right sacroiliac and gluteal region pain condition began after a shrapnel wound in June 2003 while deployed in Iraq.  The CI underwent surgery to remove the shrapnel.  Radiographic studies from 30 July 2003 showed a normal spine.  On 18 February 2004, the CI reported to the family care clinic with back pain.  During that visit, his lower back exhibited tenderness to the right paraspinal region.  The lumbosacral spine appearance was normal.  There were no muscle spasms.  Straight-leg raising (SLR) tests were negative, bilaterally.  Gait was normal.  A 15 March 2004 physical therapy (PT) examination, 14 months prior to separation, noted the CI had a non-antalgic gait.  The examiner noted there was tenderness and full active range of motion (ROM) in all directions with increased pain with forward flexion.  Radiographic studies the same day showed a normal spine.  A 15 June 2004 MRI also showed a normal lumbar spine.  

At a 21 July 2004 physical medicine and rehabilitation examination, 10 months before separation, the CI complained of thoracolumbar and internal oblique pain.  He also complained of tenderness to the lower left lumbar and sacral tissue.  Physical examination showed visually less restricted movement in the distal trunk area and limited rotation of the lumbar region.  Palpation demonstrated hypertonicity in the quadratus lumborum (deep abdominal muscle in the back) and external internal oblique muscles.  There were trigger points in the piriformis (deep gluteal) muscles.  

The 13 December 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of pain over the right lower lumbosacral region.  The CI reported running and lifting and regular daily activities made the pain worse.  Prolonged standing, push-ups, and sit ups also aggravated the pain.  The quality was sharp, throbbing, and constant as well as a pinching sensation.  He reported radiation of pain into the right leg.  Physical examination showed there was tenderness to the right gluteal muscles and sacroiliac joint.  Thoracolumbar spine ROM measurements via inclinometer, except for rotation (goniometer), were flexion 15 degrees (normal 90), extension 15 degrees (normal 30), left lateral flexion 24 degrees (normal 30), right lateral flexion 26 degrees (normal 30), right rotation 19 degrees (normal 30), and left rotation 21 degrees (normal 30).  An SLR test was negative for radicular symptoms.  The 14 February 2005 PT examination, 3 months prior to separation, recorded ROM measurements of flexion to 19 degrees and extension 15 degrees.  SLR testing was negative for radicular symptoms.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the painful right sacroiliac and gluteal region condition 10%, coded 5236 (sacroiliac injury and weakness), citing tenderness.  The panel agreed that a 40% rating, was justified for limitation of flexion not greater than 30 degrees as reported on the PT and NARSUM examinations.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 40% for the right sacroiliac and gluteal region pain condition, coded 5236.  

BOARD FINDINGS:  In the matter of the right sacroiliac and gluteal region pain condition, the panel recommends a disability rating of 40%, coded 5236 IAW VASRD §4.71a.  There are 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Sacroiliac and Gluteal Region Pain	5236	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180004915, 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 40% 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