RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01680
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20051012

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E1, Petroleum Supply Specialist, medically separated for “chronic pelvic and lumbar pain” with a disability rating of 20%.  

CI CONTENTION:  He was not treated fairly and only got 20% when others got 50% for less severe conditions.  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 - 20050805	VARD - 20060727	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pelvic and Lumbar Pain	5299-5236	20%	Chronic Lumbosacral Strain	5235	20%	20060516	
			Right Superior Pubic Symphysis Disruption 	5299-5255	20%	20060516	
			Left Inferior Pubic Ramus Fracture	5299-5255	10%	20060516	
Posterior Urethral Disruption	Not Unfitting	Posterior Urethroplasty	7518	10%	20060516	
Cognitive Disorder	Not Unfitting	Post-Traumatic Stress Disorder	
9411	
50%	20060516	
Adjustment Disorder	Not Unfitting					
Hearing Loss	Not Unfitting	Bilateral Tinnitus	6260	10%	20060516	
Headache	Not Unfitting	Post Traumatic Headaches	8199-8100	0%	20060516	
Right Clavicle Fracture	Not Unfitting	Fracture Right Clavicle	5201	20%	20060516	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Chronic Pelvic and Lumbar Pain.  The PEB combined the pelvic and lumbar conditions under a single disability rating, coded analogously 5299-5236 (sacroiliac injury and weakness) and rated 20%.  This 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 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 pelvic and lumbar conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Chronic Pelvic Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent an open reduction and internal fixation (ORIF) of the anterior pelvis and percutaneous posterior SI screw on 12 May 2004 with the postoperative diagnoses of a pelvic ring injury with symphysis pubis disruption, displaced, right pubic rami fracture and a partially unstable right SI joint.  Postoperative X-rays demonstrated ORIF changes with an orthopedic screw through the right SI joint and an orthopedic plate and screws through the right superior pubic ramus with reduction of the diastasis at the symphysis pubis.  Fractures involving both the inferior pubic rami as well as the left super pubic ramus were visualized.  The pubic rami fractures were in anatomic alignment and position after the ORIF.  Follow-up X-rays dated 30 September 2004 demonstrated healing fractures were seen in both inferior pubic rami.  There were no hardware complications.  

The 9 February 2005 MEB NARSUM addendum, 8 months prior to separation, noted complaints of 8/10 pelvic pain and right leg pain brought on by walking and climbing stairs.  The CI was unable to stand or walk for long periods or climb stairs.  Physical examination showed the CI walked with a marked antalgic gait on the right side.  His pelvis was stable to rocking.  He had tenderness over his symphysis and anterior pelvis.  There tenderness in the lower lumbar spine.  The CI’s hip had decreased flexion and full extension with discomfort with log-roll and internal/external rotation.  The examiner’s diagnosis was pelvic ring injury classified as APC (anterior posterior compression injury) II, status post ORIF.  X-rays on 9 February 2005 showed intact orthopedic hardware post ORIF of the right sacroiliac joint, symphysis pubis, right superior ramus fracture, and well-healed bilateral inferior rami fractures.  

At the neurologic evaluation dated 29 March 2005, the CI used crutches or ambulated with a cane.  Muscle strength and reflexes of the upper and lower extremities were normal.  The 11 April 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, showed an antalgic gait and pelvic pain.  X-rays of the lumbar spine on 13 April 2005 showed a screw present through the SI joint and a compression plate in the superior pubic ramus on the right.  The lumbosacral spine showed no abnormality.  

At an orthopedic examination on 19 April 2005, thoracolumbar spine pain was elicited by motion and straight leg raising (to determine nerve root irritation) was positive in both legs.  At a follow-up physical therapy visit on 12 May 2005, it was noted the CI’s gait improved and he walked taller and less abducted.  He sat with his right hip extended/slouched, although he could come close to a normal symmetric seated position with discomfort/hip pain.  A memorandum for the PEB dated 14 June 2005 indicated the CI had an antalgic gait on the right and lumbar tenderness.  Motor, sensory, deep tendon reflexes, straight leg raising, and heel and toe walking were intact.  Thoracolumbar range of motion (ROM) was 90 degrees flexion (normal) with a combined ROM of 190 degrees (normal 240).  X-rays of the pelvis dated 28 April 2006 showed old fractures involving the right and left pubic bones with callus formation, degenerative changes involving the right SI joint with mild diastasis reduced by use of a screw.  X-rays of the lumbosacral spine also dated 28 April 2006, showed ankylosis involving the right SI joint from a metallic screw.  The lumbar spine was otherwise unremarkable.  

At the 16 May 2006 VA Compensation and Pension (C&P) orthopedic evaluation, 7 months after separation, the CI reported hip and pelvic fractures with constant pain of the right anterior inguinal pelvic and proximal pelvic region and constant pain and dermatomal discomfort over the right lateral proximal pelvis where the opening for screw fixation into the SI joint was accomplished by the ORIF.  He noted if he simply patted or struck the area, there was no pain, but if he brush-stroked the skin area, there was significant discomfort, dysesthesias and pain.  He reported weakness to the right side pelvis without stiffness, fatigue or lack of endurance.  He also reported limited hip motion and a sense of increased weight to the left lower extremity versus the right.  Physical examination of the hip showed coxa obliquity (malalignment of the pelvic girdle), left more than right.  There was groin pain and pain in the anterior aspect of his right proximal thigh with flexion of the right hip 110 degrees (normal 125) with pain and left hip 125 degrees.  Extension on the right was 25 degrees and 30 degrees on the left (normal 20).  Abduction bilaterally was 40 degrees (normal 45) and adduction was 15 degrees (normal 25) bilaterally.  External ROM on the right was 45 degrees and 55 degrees on the left (normal 45).  Muscle strength was 5/5.  Trendelenburg and Patrick tests were negative for intrinsic hip problems.  X-rays of the pelvis showed fractures involving bilateral superior and inferior pubic rami with callus formation.  Fusion of the right SI joint using a metallic screw was also present.  Orthopedic devices were also seen applied to the pubic bones for repair of the prior injuries. 

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the pelvic condition with the back condition and applied a single 20% rating, coded 5299-5236 (sacroiliac injury and weakness).  The VA rated the right pubic ramus fracture condition 20%, coded 5299-5255, (femur, impairment of), based on the C&P examination, citing moderate hip disability considered approximate to malunion of the femur.  The VA also rated the left pubic ramus condition 10% (also coded 5299-5255), citing slight hip disability considered approximate to malunion of the femur.  

The panel first considered if the pelvic condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel concluded that the bundled pelvic condition was reasonably supported by the record as separately unfitting.  The panel then considered its rating recommendation for the separately unfitting pelvic condition at the time of separation.  Panel members noted the CI sustained multiple fractures of the pelvis, which had healed or were healing based on X-rays proximate to separation.  The record was silent on whether there was any muscle injury; therefore, use of a muscle code for rating was not an option.  The CI had an antalgic gait on the right side, 8 months prior to separation.  His pelvis was stable to rocking and he had tenderness over his symphysis and anterior pelvis.  The CI’s right hip had decreased flexion and full extension with discomfort with log-roll and internal/external rotation.  The VA examination showed groin pain and pain in the anterior aspect of the right proximal thigh with non-compensable ROM.  Panel members then considered various rating approaches.  Because the CI had painful motion with a noncompensable ROM of the right hip as well as X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, use of code 5099-5003 (arthritis, degenerative) offers a 10% rating option; however,  there were no occasional incapacitating episodes to warrant a 20% rating.  Panel members noted that pelvic fractures have no distinct VASRD codes, although a pelvic fracture proximate to the acetabulum raises consideration of an analogous rating of the hip under code 5299-5255 (femur, impairment of-malunion).  Panel members agreed that moderate disability of the hip rated at 20% was supported by residual hardware in the area of the right superior pubic ramus comminuted fracture, an antalgic gait on the right side and pain on the pelvic brim requiring use of a narcotic.
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the pelvic pain condition, coded 5299-5255.  

Chronic Lumbar Pain.  According to the STR and the MEB NARSUM, the CI’s back condition began in April 2004 after he sustained injuries in an IED attack.  X-rays performed on 5 May 2004 revealed a comminuted fracture of the right anterior sacrum adjacent to the SI joint, with diastasis of the right SI joint.  

The MEB NARSUM addendum noted the complaint that the CI’s back became symptomatic after stabilization of his other injuries when he was moved out of his barracks on the first floor to an upper story barracks requiring him to walk stairs.  There was tenderness in the lumbar spine.  The MEB examination showed normal flexion, but limited combined ROM to 190 degrees.

X-rays of the lumbar spine on 13 April 2005 showed a screw present through the SI joint and a compression plate in the superior pubic ramus on the right.  The lumbosacral spine showed no abnormality.  At the orthopedic clinic visit, thoracolumbar spine pain was elicited by motion and straight leg raising was positive bilaterally.  X-rays of the lumbosacral spine dated 28 April 2006 revealed ankylosis involving the right SI joint using a metallic screw.  

The C&P evaluation noted a pivot type motion to the side increased the low back pain, as did flexion and extension.  There was a resultant scoliosis noted when standing and seated.  His upper thoracic cage was rotated right high and left low when seated. When he stood, the CI’s left PSIS iliac wing was lower anteriorly versus the right.  When prone, his gluteal buttock was raised higher and the left was depressed.  A heel-to-toe walk 10 feet was with a shortened stride length.  Inspection of the pelvis showed obliquity with left low and high, right.  Palpation of the lumbar spine was negative for spasm, pain, or tenderness.  Active ROM for forward flexion was 85 degrees and combined ROM was 185 degrees.  Lower extremity strength, sensation and reflexes were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the back condition 20%, coded 5235 (vertebral fracture or dislocation), based on the C&P examination, citing injury severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed Iordosis or abnormal kyphosis.  

The panel first considered if the back condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel concluded that the bundled back condition was reasonably supported by the record as separately unfitting.  The panel then considered its rating recommendation for the separately unfitting back condition at the time of separation.  Panel members noted the diastasis of the right SI joint.  Follow-up X-rays revealed degenerative changes involving the right SI joint with mild diastasis reduced by use of a screw and ankylosis involving the right SI joint using a metallic screw.  The panel considered use of code 5236 (sacroiliac injury and weakness).  Prior to separation, the CI had tenderness of the lumbar spine and limited combined ROM to 190 degrees.  The post-separation VA examination showed forward flexion limited to 85 degrees and combined ROM limited to 185 degrees.

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) or combined ROM (greater than 120 degrees but not greater than 235 degrees) as reported on examinations proximate to separation.  There was no documented muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour.  Therefore, the next higher 20% rating was not justified on this basis.  Although the CI did have an antalgic gait to the right as well as spinal contour abnormalities, these were related to the consequences and residuals of the pelvic fractures and resultant right hip abnormality rather than muscle spasm or guarding of the lumbar paraspinal musculature.  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 recommends a disability rating of 10% for the back condition, coded 5236.  

Contended PEB Conditions:  Posterior Urethral Disruption, Cognitive Disorder, Adjustment Disorder, Hearing Loss, Headache and Right Clavicle Fracture.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled above P2 except for the hearing loss at H3, implicated in the commander’s statement, or judged to fail retention standards.  In August 2004, the CI underwent a posterior urethroplasty.  A subsequent study revealed no extravasation at the anastomosis and the suprapubic tube was removed and a follow-up study was normal.  A neuropsychological report dated 13 June 2005 indicated the CI had only a mild cognitive disorder with weakness in English language skills.  The adjustment disorder with depressed mood appeared to be related to the effects of his injuries and their impact on his life.  He was encouraged to seek both psychotherapy services and vocational counseling from the VA since he had been reluctant to take advantage of military psychotherapy services.  When he was admitted to the hospital in June 2004, he denied any difficulty with hearing, speaking or swallowing.  At a VA audiology examination on 16 May 2006, hearing was within normal limits.  The CI developed frontal headaches on a daily basis, which lasted for about 5 minutes at a time.  They were relieved by lying down.  The orthopedics NARSUM dated 9 February 2005 indicted the shoulder and clavicle symptoms resolved quickly and the CI was without complaint except for some popping in his shoulder with certain movements.  The shoulder had full ROM and the CI was non-tender.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the pelvic condition, the panel recommends a disability rating of 20%, coded 5299-5255 IAW VASRD §4.71a.  In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5236 IAW VASRD §4.66 and VASRD §4.71a.  In the matter of the contended conditions of posterior urethral disruption, cognitive disorder, adjustment disorder, hearing loss, headache, and right clavicle fracture, the panel recommends no change from the PEB determinations as not unfitting.  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, that 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 Pelvic Pain	5299-5255	20%	
Chronic Lumbar Pain	5236	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170917, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008161, 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