RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  xxxxxxxxxxxxxxxxxxxxxx	CASE:  PD-2017-02600
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070504

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Cargo Specialist, medically separated for “chronic lower back pain as manifested by mild SI [sacroiliac] joint dysfunction,” “pes cavus with ongoing chronic left hip pain secondary to great trochanteric bursitis,” “left gluteus medius muscle tear” and “left quadratus femoris muscle tear,” rated 10%, 0%, 0% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  “Review all 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 - 20070320	VARD - 20081106	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lower Back Pain… SI Joint Dysfunction	5237	10%	Low Back Condition (Also Claimed as Sciatica)	5237	10%	20080721	
Pes Cavus with Ongoing Chronic Left Hip Pain…	5299-5278	0%	Left Hip Condition with History of Stress Fracture…	5010-5250	0%	20080721	
Left Gluteus Medius Muscle Tear	5317	0%	Left Gluteus Medius Muscle Tear	5317	0%	20080721	
Left Quadratus Femoris Muscle Tear	5318	0%	Left Quadratus Femoris Muscle Tear	5318	0%	20080721	
Status Post [S/P] Stress Fracture of Left Hip	Not Unfitting	Left Hip Condition with History of Stress Fracture…	5010-5250	0%	20080721	
S/P Post Ischiopubic Ramus Stress Fracture	Not Unfitting					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Lower Back Pain…Mild SI Joint Dysfunction.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in August 2005 during basic training.  Hip X-rays and a bone scan showed an ischiopubic ramus stress fracture on the right, but the left side was negative; however, her symptoms were on the left.  A left hip MRI showed a stress reaction of the femoral head which was treated conservatively.  A lumbar spine MRI in May 2006 showed degenerative disc disease at L3-4 and L4-5, without disc herniation or nerve impingement.  The CI continued to report left side SI joint symptoms and left lower extremity (LLE) sciatic type pain, without paresthesia or weakness, and a hip MRI on 26 June 2006 showed a muscle injury of the left quadratus femoris muscle near the ischial insertion.  There was also evidence of a possible gluteus medius muscle injury located on the right, asymptomatic side.  There was no femoral stress fracture or abnormality of the cartilage surfaces, and the bones of the pelvis and hips were normal.  

At the 3 January 2007 orthopedic examination, 4 months prior to separation, the CI reported radicular pain aggravated by running, jumping, climbing into and out of vehicles, and at times,  by simply walking.  Physical examination showed normal lumbosacral motion without tenderness or muscle spasm, and testing maneuvers to elicit radicular symptoms were negative.  Strength, sensation and reflexes were normal.  At the 21 February 2007 MEB NARSUM examination, 2 months before separation, the CI complained of LLE radicular symptoms with pain radiating down the left leg to the mid-calf.  Physical examination showed a normal gait, stance, spinal curvatures, LLE strength, sensation and reflexes.  There was tenderness of the left SI joint, sciatic notch, left greater trochanteric (lateral hip) and inguinal areas, but none noted along the lumbar midline or paravertebral region.  Testing to elicit SI joint pain reproduced the inguinal pain, but not the SI joint pain, and maneuvers for hip and bone pain (femur) were otherwise negative.  

At the 21 July 2008 VA Compensation and Pension (C&P) examination, 15 months after separation, the CI reported intermittent LLE numbness and tingling, and occasional pain radiating from the left hip to the LE, as often as 3 times a week.  The examiner noted no symptoms, current treatment or functional impairment due to the condition, and flexion was to 90 degrees (normal) with a combined ROM of 240 degrees (normal), with no painful motion or additional joint function limitation after repetition. There was no spinal, paravertebral muscle or SI joint tenderness, spasm or radiating pain with movement, but there was painful left hip motion (see below).  There were no radicular symptoms bilaterally, and lumbar spine X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain), citing tenderness over the left SI joint.  The VA also rated the low back condition 10%, coded 5237, based on the C&P examination, citing 10% thoracolumbar ROM criteria.  Panel members noted that although there was insufficient limitation of motion to support a compensable rating, a 10% rating was justified for the presence of SI joint tenderness at the MEB NARSUM examination.  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.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration under that alternate VASRD formula.  Additionally, IAW VASRD §4.66 (sacroiliac joint, the sacroiliac joints and the thoracolumbar spine are rated as a single spinal segment.  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 low back condition.  

Sciatica was contended by the CI and the panel next considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  However, there was no evidence of lumbar nerve root involvement by MRI, and while the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty, and so the panel concluded that an additional disability rating was not justified on this basis.  

Left Foot Pes Cavus with Ongoing Chronic Left Hip Pain.  The MEB referred “chronic left hip pain secondary to greater trochanteric bursitis,” and the PEB re-characterized the condition as “pes cavus [high arches] with ongoing chronic left hip pain secondary to greater trochanteric bursitis.”  According to the STR and MEB NARSUM, the CI’s left foot condition began prior to service entry, and was documented on the military enlistment physical as mild and asymptomatic.  At a treatment visit on 13 October 2005, she reported a sore left foot with swelling, with the pain gradual in onset, on the top of the foot, and worsened by weight bearing.  Physical examination revealed no calluses, swelling, redness, or warmth, and no pes cavus or pes planus (flatfoot).  There was tenderness of the lateral aspect of the foot, but foot motion was normal, without pain, and there were no toe abnormalities.  There were no STR notes linking the CI’s left hip pain to the mild pes cavus, which was likely related to the torn quadratus femoris muscle that inserts on the intertrochanteric ridge of the femur (between the greater and lesser trochanters).  According to the NARSUM, the CI was treated with a steroid injection which relieved the greater trochanteric bursitis, but with activity, the hip pain remained.  

At the 24 January 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the examiner noted mild, asymptomatic pes cavus.  The MEB NARSUM examination did not address either foot, with the CI reporting only chronic left hip pain.  Physical examination showed a normal gait, stance, spinal curvatures, LLE strength, sensation and reflexes.  There was left SI joint, sciatic notch, left greater trochanter and inguinal region tenderness.  Maneuvers to elicit SI joint pain reproduced the inguinal pain, but not the SI joint pain.  There was painful left hip motion with external rotation (quadriceps femoris muscle is a strong external rotator of the hip), but no bone pain.  

At the C&P examination, the CI reported intermittent left hip stiffness with history of a left hip stress fracture and possible tear of the left quadratus and the [right] gluteus medius muscles. The examiner noted no current treatment or functional impairment due to the foot or hip conditions.  Physical examination of the feet showed no evidence of pes planus, deformity, tenderness, calcaneal tendonitis, calcaneal tendon misalignment, pes cavus, varus deformity, pain with dorsiflexion of toes, pain of the metatarsal heads, hammer toes, interdigital neuroma, hallux valgus, hallux rigidus, pain with standing or walking, or use of corrective shoe wear.  The CI was able to stand and ambulate without difficulty, and ankle range of motion (ROM) was normal bilaterally without painful motion.  Physical examination of the left hip was normal, without tenderness, guarding of movement, fracture, swelling, subluxation, or ankyloses.  Muscle strength was graded 5/5 for all muscle groups, and hip ROM was normal in all planes, without painful motion.  There was no additional functional loss of the joint motion after repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot pain due to trochanteric bursitis 0%, analogously coded 5278 (claw foot [pes cavus], acquired).  The PEB determined the pes cavus was a congenital condition that existed prior to service with evidence of permanent service aggravation, and assigned a 0% rating.  The original VA Rating Decision did not address any foot condition and only rated the left hip condition 0%, dual coded 5010-5250 (traumatic arthritis-hip ankylosis), citing painful or limited motion a major joint or group of minor joints.  Panel members agreed there was no evidence of pes cavus with great toe dorsiflexion, limitation of ankle dorsiflexion, or definite tenderness under the metatarsal heads for greater than a 0% rating of one or both feet.  The panel considered other VASRD foot codes but all were less applicable.  There was therefore no higher than a 0% rating supported for the left foot condition.  As noted above, the pes cavus did not cause the chronic left hip pain, and the trochanteric bursitis (likely a result of the CI’s left hip injuries) was resolved with a steroid injection.  Hip pain, whether from bursitis, residuals of a stress fracture, or a muscle tear cannot be the basis for more than a single rating IAW VASRD §4.14.  Therefore the panel agreed since the bursitis itself seemed to be resolved by the time of separation, addressing the chronic hip pain as bursitis was suboptimal and the rating recommendation for the hip pain is addressed below under the quadratus condition.  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 left foot condition.  

Gluteus Medius Muscle Tear.  According to the STR and MEB NARSUM, the CI’s gluteus medius condition began in August 2005 during basic training.  As noted above, imaging in June 2006 showed possible evidence of a right gluteus medius muscle injury or partial tear.  The CI reported low back and left hip pain, but no symptoms of the right SI joint, hip, pelvis, or inguinal area.  The MEB NARSUM examination noted no complaints related to the right hip or pelvis.  Physical examination noted tenderness of the left SI joint, but no findings for the right hip or pelvis.  

At the C&P examination, the CI did not report any right-sided symptoms of the LE, SI joint, or pelvis.  Physical examination of the right hip was normal, without tenderness, guarding of movement, fracture, swelling, subluxation, lacking pain or ankyloses.  Muscle strength was graded 5/5 for all muscle groups.  There was no evidence of fasciitis, myalgia, shrapnel or bullet wounds, intermuscular scarring, bone adhesions, lowered endurance, impaired coordination, muscle herniation, muscle injury, tendon damage, bone damage, joint damage or neurologic dysfunction.  Hip ROM was normal in all planes, without painful motion or loss of additional joint function after repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left gluteus medius condition 0%, coded 5317 (muscle group XVII.  Function: abduction of the thigh, elevation of the pelvis [includes gluteus medius muscle]), citing, 5/5 muscle strength and intact sensation.  The VA also rated the gluteus medius condition 0%, coded 5317, based on the C&P examination, citing slight muscle injury.  The panel noted that the hip MRI in June 2006 showed possible injuries/partial tears of the right gluteus medius and left quadratus femoris muscles, and while the NARSUM also noted these conditions, the PEB rated a “left” gluteus medius tear.  The CI did not report any symptoms related to the right side of the low back, or right buttock or hip.  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 [right] gluteus medius condition.  

Left Quadratus Femoris Muscle Tear.  According to the STR and MEB NARSUM, the CI’s left quadratus femoris muscle condition began in August 2005 during basic training with reports of left hip pain, which was initially diagnosed as a left groin strain.  She completed basic and advanced individual training without incident.  A left hip MRI showed a stress reaction of the femoral head, and despite conservative treatment, she reported increased pain at an orthopedic examination on 31 March 2006.  The June 2006 MRI showed a tear of the left quadratus femoris muscle at the insertion on the ischium (originates on the ischial tuberosity and inserts on the femur below the greater trochanter and is a strong rotator of the hip) without evidence of a femoral stress fracture or hip/pelvis bone abnormalities.  At an orthopedic visit on 6 November 2006, painful left hip motion was noted with greater trochanter tenderness.  Hip X-rays showed a healed femoral neck stress fracture.  As noted above, the MEB and NARSUM examination findings documented complaints of chronic left hip pain but normal gait, stance, spinal curvatures, LLE strength, sensation and reflexes.  There was left SI joint, sciatic notch, greater trochanter and inguinal tenderness, as well as painful left hip motion with external rotation.  

At the C&P examination, the CI reported intermittent left hip stiffness, but denied any current treatment or functional impairment.  Physical examination of the left hip was normal with full ROM in all planes, and no pain or additional functional loss after repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left quadratus femoris muscle condition 0%, coded 5318 (Grp XVIII. Function: outward rotation of thigh and stabilization of hip joint), citing 5/5 muscle strength and intact sensation.  The VA also rated the left quadratus femoris muscle condition 0%, coded 5318, citing slight muscle disability.  As noted above, there was no evidence in the record that the CI’s left hip condition was related to the congenital foot condition.  However, she had a left femoral head stress fracture (which healed) and quadratus femoris muscle injury which likely contributed to the left hip pain.  Panel members considered a rating under §4.73 (muscle injuries), and noted evidence of pain with use and posterior/anterior hip joint tenderness for a 10% rating for moderate muscle injury.  There was no objective evidence of a sufficiently severe mechanism of injury or muscle injury, such as muscle weakness or atrophy, to support a higher rating for moderately severe muscle injury.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left quadratus femoris muscle condition, coded 5318.  

Contended PEB Conditions:  S/P Left Hip Stress Fracture and S/P Ischiopubic Ramus Stress Fracture.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The left hip stress fracture was profiled, implicated in the commander’s statement and failed retention standards.  However, proximate to separation, imaging, including X-rays and MRI, showed the hip stress fracture had healed (also noted in the commander’s statement).  The right ischiopubic stress fracture was not profiled or implicated in the commander’s statement and did not fail retention standards.   There was no performance-based evidence from the record that these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determinations for the contended left hip and ischiopubic ramus conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left pes cavus and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left gluteus medius muscle tear and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left quadratus femoris muscle tear, the panel recommends a disability rating of 10%, coded 5318 IAW VASRD §4.73.  In the matter of the contended left hip and ischiopubic ramus stress fractures, 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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Lower Back Pain 	5237	10%	
Pes Cavus With Ongoing Chronic Left Hip Pain Secondary To Trochanteric Bursitis	5299-5278	0%	
Left Gluteus Medius Muscle Tear	5317	0%	
Left Quadratus Femoris Muscle Tear	5318	10%	
COMBINED	20%	

The following documentary evidence was considered:  

Exhibit A.  DD Form 294, dated 20170330, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record 

AR20190011718, 

Dear xxxxxxxxxxxxxxxx:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

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