RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX		CASE: PD-2017-01126 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20060602

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Cable Systems Installer/Maintainer, medically separated for “coccygeal pain” with a disability rating of 10%.

CI CONTENTION:  No specific contention was made.  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 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 - 20060603	VARD - 20070518	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Coccygeal Pain	5299-5236	10%	Coccygeal and Sacroiliac Sprain	5237-5298	10%	20070305	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Coccygeal Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s coccyx pain began in June 2004 after falling while hiking. Serial X-rays showed prominent angulation of the coccyx anteriorly, but no findings diagnostic of fracture. An MRI also showed marked angulation of the sacrococcygeal junction, but the spinal surgeon did not recommend surgery. During the 3 February 2006 MEB examination (recorded on DD Forms 2807- 1 and 2808), 4 months prior to separation, the CI reported chronic lower back pain. Physical examination showed tenderness. Range of motion testing showed 100 degrees of flexion (normal 90), after repetition. The 3 February 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of 3/10 pain that flared to 9/10 with bending activities and prolonged sitting. Physical examination showed “normal walk, heel-toe, jog [and] jump.” Spinal flexion was 100 degrees (normal 90), after repetition. There was tenderness of the sacroiliac joints. A focused examination of the coccyx showed no complaint of pain with extraneous pressure, but significant tenderness in the right buttock.  There was no evidence of coccydynia.

At the 5 March 2007 VA Compensation and Pension (C&P) examination, 9 months after separation, the CI reported 4/10 pain in her coccygeal area that flared to 7/10.         She avoided

bending or lifting more than 20 pounds. Sitting aggravated the condition, but the CI could stand and walk without problems. Physical examination showed a normal appearing sacrococcygeal area. There was full ROM of the thoracolumbar spine without discomfort, and repetitive motion did not produce pain, limitation of motion, weakness, fatigue or incoordination.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the coccyx condition 10%, analogously coded 5299-5236 (sacroiliac injury and weakness), citing tenderness. The VA also rated the coccyx condition 10%, dual coded 5237-5298 (lumbosacral strain – coccyx removal), based on the C&P examination. Panel members agreed that the coccyx had not been removed, so a rating could not be supported under code 5298. However, a 10% rating was justified for the presence of tenderness and functional loss. There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis. The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the coccygeal pain.

BOARD FINDINGS: In the matter of the coccygeal pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. There are no other conditions within the panel’s scope of review for consideration. Therefore, the panel recommends no modification or re- characterization of the CI’s disability and separation determination.

XXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXX

	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.