RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-02492
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060709

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Construction Repairer, medically separated for “chronic right buttock and leg pain” with a disability rating of 20%.  

CI CONTENTION:  Review requested of the separating condition and of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  The complete submission is at Exhibit A.    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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20060426	VARD - 20061208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Buttock and Leg Pain	5099-5003	20%	Residual Shrapnel Injury Muscle Group XVIII, Right	5318	20%	20061101	
			Residual Shrapnel Injury Muscle Group XVI, Right	5318	10%	20061101	
			Residual Shrapnel Injury Muscle Group XIII, Right	5318	10%	20061101	
Adjustment Disorder with Depressed Mood	Not Unfitting	Post-Traumatic Stress Disorder (PTSD)	9411	NSC	20060914	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Right Buttock and Leg Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right buttock/leg pain condition began in December 2004 after being injured in a suicide bomber attack while in the dining facility in Iraq.  He sustained a shrapnel injury to his right buttocks.  The CI sustained a 1.5 cm laceration to the right upper buttocks located just lateral to the top of the gluteal cleft.  There were also two small lacerations to the right and left lower extremities without significant injury.  The CI was able to walk to the aid station and the laceration was cleaned and irrigated.  He was initially returned to duty but later visits in the STR indicated he was seen for wound packing for 3 weeks and was on crutches for 2.5 weeks. 

In January 2005, the CI reported pain with movement in the right lower extremity (RLE) and X-rays on 10 January 2005 showed no fracture, but there was a small shrapnel piece in the right posteriomedial thigh.  Radiographs in February 2005 noted the shrapnel in the thigh was not moving and an orthopedic consult did not recommend surgically removing it.  At a sports medicine examination the CI reported he had recovered from the wounds, but continued to have pain in the right buttocks that shot below the knee with running, squatting, pushing off, or bearing weight on his right leg.  On physical examination there was tenderness over the sciatic notch with reproduction of the radicular pain.  He was treated with physical therapy for sciatica and at a sports medicine follow-up on 25 April 2005, the CI reported improvement in his strength, but noted continued pain of the buttocks and thigh, but the thigh was worse.  He reported thigh pain since the injury, which occasionally radiated further and was aggravated by running or prolonged standing.  Physical examination noted tenderness to deep palpation of the thigh, which continued to hurt if the CI tried to walk or squat.  

A CT scan performed on 11 May 2005 showed a non-acute fracture of the ischial tuberosity (IT) which is the “sit bone,” origin of the hamstring muscles. There was also possibly an avulsion fracture, and a 10 mm ovoid metallic density was noted in the posteromedial right upper leg that was not near the expected location of the sciatic nerve.  The lumbar spine was normal.  At the physical medicine examination on 12 May 2005, the CI reported pain in the right posterior thigh and weakness of the right calf.  Physical examination showed a normal gait and station.  There was tenderness over the IT area and the medial hamstrings (semimembranosus and semitendinosis).  Hip and back range of motion (ROM) were normal.  Strength was decreased in the calf, graded 4/5 and the CI was unable to hop or stand on his toes on the right foot.  There was also trace weakness of knee flexion.  Reflexes and sensation were normal.  The pain specialist thought pain was due to the IT fracture and hamstring muscle injury; sciatic nerve injury was also suspected.  Electrodiagnostic studies on 19 May 2005 did not show evidence of lumbar radiculopathy or sciatic neuropathy; there was no evidence of active or chronic muscle denervation in the anterior/posterior thigh or anterior/posterior calf muscles.  Examinations in the STR noted normal back and hip ROM.  

At a primary care visit on 23 July 2005, 12 months prior to separation, the CI reported right thigh pain that extended from the buttocks to the mid-calf.  He denied weakness of his calf or hamstring muscles.  Physical examination showed a healed 1.5 cm wound of the upper right buttocks and tenderness of the right thigh from the IT to the medial thigh.  There was full strength of knee flexion/extension, ankle dorsiflexion (DF)/plantar flexion (PF), and great toe flexion/extension.  Sensation was intact 

A 13 October 2005 MEB orthopedic consultation, 9 months prior to separation, noted complaints of significant pain described as burning that extended down the posterior leg to the foot and some weakness of the RLE.  Physical examination showed the entry wound near the top of the gluteal cleft, without an exit wound.  There was “minimal” tenderness over the IT and lateral aspect of leg.  Straight leg raise testing (SLR) to elicit radicular symptoms was negative.  All motor groups were described as intact, with pain reported during push-off activities as well as DF of the foot; DF strength was graded 4/5.  Radiographs showed a foreign body of the medial thigh and a well healed inferior IT fracture.  The assessment was sciatic nerve-related pain.  

During the 21 November 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported daily LBP and right sciatica.  Physical examination showed tenderness over the right sciatic area and SLR testing to elicit radicular symptoms was reported as painful at 90 degrees bilaterally.  

A pain clinic visit on 19 December 2005, 7 months prior to separation, noted the CI had been treated with multiple pain interventions including sciatic nerve block, lumbar sympathetic block, and a diagnostic facet block, without persistent relief of the RLE pain.  The CI reported RLE pain with no difficulty ambulating.  Physical examination noted a normal gait.  There was no tenderness of the back with normal ROM, negative SLR and negative testing for sacroiliac or hip joint pain.  There was tenderness of the IT.  Sensation and motor were intact.  The assessment was chronic myofascial leg pain with no evidence of peripheral neuropathy or radiculitis.  The pain specialist indicated the CI’s pain was “fairly well controlled” at the time and no further invasive procedures were recommended.  

The 10 January 2006 MEB NARSUM examination, 6 months prior to separation, noted complaints of right leg pain.  The CI reported constant sharp pain in the right buttock and posterior thigh graded 5/10, that worsened with running or jumping, sitting for more than 15 minutes, or walking more than 1 mile.  Physical examination showed a well-healed 2 by 2 cm shrapnel entrance wound over the right buttock, without tenderness, drainage, or swelling.  Lumbar spine ROM was full, with negative SLR bilaterally.  There was full ROM of the right hip joint.  There was tenderness of the right IT and lateral aspect of the leg.  Right foot DF strength was graded 4/5 and otherwise strength was 5/5.  Lower extremity reflexes, sensation, and pulses were intact.  The MEB NARSUM examiner determined the CI did not meet retention standards due to chronic myofascial pain following the shrapnel wound and the IT avulsion fracture.  

A 24 March 2006 orthopedic examination, 3 months prior to separation, noted complaint of mechanical, irritating, disabling right leg pain.  The CI also reported some weakness secondary to pain with hip flexion and knee extension.  He reported LBP as well, which the examiner noted was likely due to compensatory gait.  Physical examination showed a palpable mass in the posterior medial thigh.  Sensation and reflexes were normal and SLR was negative.  Lower extremity motor strength was normal on the left and graded 4/5 on the right with “giveaway due to pain.”   The assessment was “irritative retained debris.”  The CI was offered the option of surgical removal of the metal piece and he was going to think about it and likely follow up with the VA.  

At the 28 August 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant pain in the RLE.  He took muscle relaxants and nerve-related pain medication.  He reported loss of strength, weakness, easy fatigability, pain, and impairment of coordination.  He reported at the time of pain he could function with medication.  Physical examination showed an abnormal gait favoring the right leg.  There was no adherence of the underlying structures with intermuscular scarring and no adhesion to the bone.  On palpation loss of deep fascia and muscle substance was noted.  There were signs of lowered endurance in the right leg.  Strength of muscle Groups XI (calf), XIII (hamstring), and XVIII (piriformis) were all graded 4/5.  Thoracolumbar ROM was flexion 90 degrees and combined ROM was 230 degrees, with painful motion and additional limitation of motion by 30 degrees after repetition due to pain fatigue, weakness, and lack of endurance, with the latter having the major functional impact.  SLR testing to elicit radicular symptoms was negative bilaterally.  There was decreased strength of foot and great toe DF, graded 4/5, and sensory decrease over the top of the foot.  Later in the same examination right ankle DF and PF were noted to be normal and were not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  Right hip and knee ROM were also normal, with no additional limitations after repetition due to pain, fatigue, weakness, lack of endurance, or incoordination.  Right hip/pelvis X-rays were unchanged and right tibia, fibula X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the buttock/leg condition 20%, analogously coded 5009-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  The VA rated the buttock/leg condition as three separate muscle groups rated 20%, 10%, and 10%, respectively, coded 5318 (Group XVIII) 5311 (Group XI) and 5313 (Group XIII).  

The panel first considered a rating for the CI’s residuals of shrapnel injuries IAW VASRD §4.73 (muscle injuries).  The evidence supports injury to muscle Group XVII (pelvic girdle group-includes gluteal muscles) with the entry wound located medially next to the gluteal cleft and Group XIII (includes hamstring muscles) evidenced by imaging noting the location of the shrapnel and clinical examination findings.  In the STR  examinations –prior to separation primary care (12 months), pain clinic (7 months), MEB NARSUM (6 months) and the orthopedic (3 months), strength was documented as full or intact, with only foot DF graded 4/5 at two of four examinations (normal strength throughout was documented at two of the examinations).  At those two examinations foot DF was associated with pain and the orthopedic the examiner had noted global RLE strength, all graded 4/5, with give- way on testing due to pain.  There was neither direct calf muscle injury nor shrapnel noted in either lower leg on X-rays.  The pain clinic and MEB NARSUM examinations noted tenderness of the IT and/or thigh, and the MEB NARSUM specifically noted there was no tenderness of the right buttocks.  

The VA examination 2 months after separation noted weakness of the piriformis, hamstrings, and calf muscles of the RLE, all graded 4/5.  However at examinations in the STR proximate to separation the mild weakness, when noted, was attributable to strength limitation due to pain.  Additionally there appeared to the panel majority to be some conflicting evidence within the VA examination such as strength of the hamstring and calf muscles was graded 4/5, but in a later section the VA examiner indicated full active ROM of the hip, knee, and foot with no change due to pain, fatigue, weakness, or lack of endurance even after repetition.  No muscle atrophy was noted at any examination in record.  

Members agreed the CI’s disability due to the Group XVII injury was more nearly approximated by the slight muscle injury criteria than the moderate criteria based on a well- healed approximately 2 cm non-tender wound.  At examinations in the STR proximate to separation, there was no evidence of Group XVII muscle weakness based on findings of a normal gait and no mention of difficulty with leg extension, abduction, or balance when ambulating and there was no deformity, atrophy, tenderness, or spasm of the buttocks muscles noted on examinations.  Earlier in the course of the injury the CI had evidence of sciatic irritation due to his injuries, but following treatment, examinations beginning 7 months prior to separation noted tenderness located in the area of the IT and thigh muscles, without buttocks tenderness or spasm and testing to elicit radicular symptoms was negative.  The panel majority agreed the CI’s disability due to the Group XIII injury was more nearly approximated by the moderate muscle injury criteria than the moderately severe criteria.  This determination was based on a single, small, retained shrapnel element with persistent pain limiting use of the RLE and mild weakness (possibly pain related), without major loss of soft tissue or muscle substance.  In the minority member’s opinion the CI’s disability due to the Group XIII was more nearly approximated by the moderately severe criteria.

The right lower leg weakness noted at STR examinations involved DF and/or PF at different examinations and appeared to be due to pain and not true muscle weakness based on the absence of history of direct muscle trauma, negative EMG, and the orthopedic assessment in March 2006.  Therefore, members agreed an additional muscle rating for the lower leg weakness could not be recommended IAW VASRD §4.14 (avoidance of pyramiding), which states that a single symptom (pain) cannot be used as the basis for two ratings under different diagnoses.  

The panel considered if alternative or additional rating for nerve-related impairment was warranted in this case as some of the CI’s pain was thought to be due to sciatic nerve irritation from muscle injury or scarring.  According to VASRD §4.55, a peripheral nerve rating may only be provided in addition to a muscle rating if the injuries affect entirely different functions.  Although early in the course of his injury, the CI did have evidence of sciatic irritation, electrodiagnostic testing was negative for evidence of sciatic neuropathy.  Examinations in the year before separation noted no RLE sensory or reflex changes and the variable decreased strength appeared to be due to pain limitation as discussed above.  Also as noted above, examinations beginning 7 months prior to separation all noted negative testing for radicular pain.  The panel concluded that an additional rating for nerve injury was not warranted and the residual disability at separation was best coded as muscle injury based on the medical evidence.  The panel had also considered alternatively rating the CI’s right buttock and leg pain under 5299-5236 as residuals of the IT fracture, however this was reportedly well healed and the evidence for rating under the General Formula for Rating Diseases and Injuries of the Spine supported a 10% rating, which provided no benefit.  

After its deliberations, the panel majority concluded the evidence did not support a rating higher than that adjudicated by the PEB.  The panel majority noted the PEB’s reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating and therefore no change to the PEB’s coding choice is recommended.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the buttock/leg pain condition.  

Contended PEB Condition:  Adjustment Disorder with Depressed Mood.  The CI contended PTSD which was not a condition on the MEB or one adjudicated by the PEB.  However, the CI was diagnosed with adjustment disorder with depressed mood, a condition not constituting a physical disability IAW DoDI 1332.38, enclosure 5.  Therefore, the panel has no basis for recommending it as unfitting.  

BOARD FINDINGS:  In the matter of the buttocks/leg pain condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends re-characterization, with a 0% rating coded 5317, and 30% rating, coded 5313 IAW VASRD §4.73 and did not elect to submit a minority opinion.  In the matter of the contended adjustment disorder with depressed mood, the panel agrees it cannot recommend it for additional disability rating.  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.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170313, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190011628, XXXXXXXXXXXXXXXXXX

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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.