RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-02915 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20090130

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Rifleman, medically separated for “status post sacroiliac fusion” with a disability rating of 20%.

CI CONTENTION: “It should be changed because it is not sufficient with lower back pain, knee, and joint pain…”  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 - 20081015	VARD - 20090218	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post Sacroiliac Fusion	5241	20%	Hip Osteoarthritis	5010-5252	10%	20081028	
			Lumbar Spine Strain	5237	10%	20081028	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Status Post Right Sacroiliac Fusion. According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent right sacroiliac fusion in December 2007. Following the surgery he was able to ambulate, but the pain continued. At the 31 July 2008 MEB NARSUM examination, 6 months prior to separation, the CI reported being unable to run or jump, walk more than five blocks or sit more than 30 minutes, all due to pain. Provocative testing was positive for hip and/or sacroiliac (SI) joint pain. Hip range of motion (ROM) testing showed flexion of 105 degrees (normal 125), internal rotation of 30 degrees (normal 40) and external rotation of

80 degrees (normal 60). Strength was normal. Hip X-rays showed two plates and an iliosacral screw over the SI joint.  There was complete obliteration of the joint and solid fusion mass.

At the 28 October 2008 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported persistent lower back pain, right radiating SI joint pain, stiffness, locking and frequent popping without weakness, swelling, giving way, lack of endurance, fatigability or dislocation. The pain was aggravated by activity, but the CI reported he could function without medication and denied incapacitation over the last 12 months due to the condition. The CI did not require any assistive device for ambulation. Physical examination showed normal spinal contours and a well healed scar of the lateral hip. The CI’s gait was normal and there was no muscle spasm or radiation of pain on movement, but there was tenderness of the right SI joint. Thoracolumbar ROM was flexion of 80 degrees and combined ROM of 200 degrees with painful motion. There was no additional limitation of motion after repetition. The right hip showed no swelling, weakness, abnormal movement or subluxation. There was tenderness of the lateral hip with guarding of movement. Hip flexion was 110 degrees, extension was 30 degrees (normal), adduction was 25 degrees (normal), and abduction was 40 degrees (normal 45), external rotation was 50 degrees and internal rotation was 30 degrees, with painful motion. There was no additional limitation in degrees after repetitive use. Strength was normal. Lumbar spine X-rays were normal but hip X-rays showed early osteoarthritis. The VA examiner noted that the CI did not have clear evidence of intervertebral disc syndrome or radiculopathy but noted there was tenderness of the SI joint, but none in the spinal region.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the SI fusion 20%, coded 5241 (spinal fusion). The VA rated the SI fusion as a hip condition 10%, coded 5010-5252 (posttraumatic arthritis-limitation of thigh flexion) based on the C&P examination, citing tenderness and guarding of the hip with painful motion. The VA also rated the SI fusion as a back condition 10%, coded 5237 based on the C&P examination, citing limited and painful motion.
There was evidence of painful hip motion with functional loss supporting a 10% rating (based on
§4.59, §4.40 and §4.45) as reported on the MEB NARSUM and VA examinations. There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh flexion or extension, or thigh impairment (5251, 5252, 5253). There was no evidence of hip ankyloses, flail hip joint or femur impairment (5250, 5254, 5255) for a rating under the respective codes for those conditions.

A 10% rating for the back was also supported under code 5236 (sacroiliac injury and weakness) for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the VA 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 documentation of intervertebral disc syndrome with incapacitating episodes, which would provide for a higher rating under that formula. The panel concluded there was no evidence to support a combined rating higher than the 20% 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 SI fusion.

BOARD FINDINGS: In the matter of the SI fusion 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.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170326, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

	

DEPARTMENT OF THE NAVY
SECRETARY OF TIIE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN   REPLY  REFER  TO,
1850
CORB: 003 20May20

From: 

Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr <ltd 25 Apr 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.