RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03133
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O4, Formal Training Instructor, Trainer Pilot, medically separated for “chronic low back pain (LBP) with associated hip pain” with a  disability rating of 10%.  

CI CONTENTION:  “Review all conditions. While on active duty, my chronic hip pain ‘stressed hips’ was never alleviated.  An incorrect diagnosis led to several different inappropriate treatments to include unnecessary denervation at my SI [sacroiliac] joint.  I still experience chronic pain in my left hip and the source is still undiagnosed.”  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 - 20090505	VARD - 20100712	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP with Associated Hip Pain	5243	10%	DDD, Lumbar Spine	5236-5242	10%	20100224	
			Iliotibial Band Syndrome	5253	NSC	20100224	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic LBP with Associated Hip Pain.  The PEB combined the low back and right hip conditions under a single disability rating, coded 5243, and rated 10%.  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 noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 low back and right hip conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s LBP began without trauma or injury in early 2000 while flying.  She underwent a discectomy of L5-S1 in 2001 with complete resolution of symptoms.  In the spring of 2006 she noted right hip pain began to affect her daily activity.  Conservative therapy was to no avail.  X-rays dated 22 October 2007 of the right hip were normal and a transitional vertebral body with pseudoarticulation on the right was noted to potentially be a source of pain.  At an orthopedic clinic visit on 8 November 2007, examination of the lumbosacral spine showed a sitting forward bend test was positive at the right side of the SI joint and straight leg testing (to determine nerve root irritation) was normal as was the right hip.  

On 30 November 2007 the CI received injections of a steroid/anesthetic into the articulation between the transverse process of L5 and the superior portion of the sacrum.  She had a couple of days of relief, but the hip pain returned.  At a neurosurgical consultation on 4 January 2008, she complained of constant LBP and was able to flex to her toes.  No neurological symptoms were evident.  An MRI dated 16 January 2008 demonstrated a transitional L5 vertebra pseudoarticulation on the right, evidence for the previous microdiskectomy at L4/5 without protrusion with some degenerative disc disease (DDD) and asymmetric facet hypertrophy resulting on the right and engaging the L5 root at the lateral recess, and a probable congenital slightly narrow canal at L5/S1 further narrowed by facet disease without direct nerve root compromise. In a follow-up neurosurgical visit on 30 January 2008, the neurosurgeon did not feel there was any indication for surgery and referred the CI for pain management.  

On 22 April 2008 the CI underwent a series of L3-S2 medial branch blocks, L5 dorsal root ganglion blocks bilaterally, and multiple trigger point injections and along with at least two sessions of physical therapy.  X-rays of the hips dated 26 June 2008 showed normal hips bilaterally.  She then underwent right denervation from L3-S3 along with trigger point injections and nerve root blocks at L3 to L5 on 5 August 2008.  On 9 September 2008 she underwent left denervation from L3 to S2 along with left nerve root blocks at L4 and L5 on the left and L5 on the right along with trigger point injections.  At an orthopedic examination on 22 September 2008, the CI reported improvement of the back pain, but persistence of the right hip pain.  She had positive Gaenslen’s/FABER testing with pain at the right hip and pain along the gluteus medius and piriformis muscles.  A SPECT scan on 21 October 2008 showed a small focus of increased tracer uptake to the right of the midline at the level of S1, which could have represented uptake in the right facet joint at “L6/S1” that might have explained her pain.  The SI joints appeared normal.  

At an orthopedic examination on 3 November 2008, hip range of motion (ROM) was painless from 0-130 degrees (normal 0-125) and there were otherwise unchanged findings from the 22 September 2008 examination.  The pain management specialist noted the CI had an orthopedic consultation where a fusion of the right SI joint was recommended; however, he offered radiofrequency denervation as an option rather than surgery; the consulting neurosurgeon also recommended against surgery.  The commander’s statement dated 5 February 2009 indicated no one has successfully diagnosed the cause of the CI’s “back/hip pain.”  

The 12 February 2009 MEB NARSUM examination, 7 months prior to separation, noted the complaint of chronic back pain.  Physical examination was deferred to physical medicine.  At a same-day physical medicine clinic visit there was no guarding of active movements and no apparent lumbar or pelvic asymmetry.  There was a full squat to the floor without acute distress or difficulty due to back pain.  She had normal functional strength with walking on toes and heels. Slump testing, straight leg raising (to determine nerve root pain), FABER testing (for back and hip pain), and piriformis testing (for buttock or sciatic pain) were all negative.  There was no evident sacral asymmetry in prone, neutral, or extension positions.  Trunk ROM was within functional limits. Muscle strength and deep tendon reflexes of the lower extremities were normal.  Thoracolumbar ROM measurements were flexion 85 degrees (normal 90) and combined ROM 215 degrees (normal 240), all motions were with pain.  Right hip ROMs were flexion 113 degrees, extension 8 degrees (normal 20), abduction 35 degrees (normal 45) and external rotation 35 degrees (normal 45), with pain.  The examiner’s diagnosis was chronic LBP with associated right SI joint pain with no real deficit with ROM noted and no neurological signs and symptoms.

At the 24 February 2010 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported continuous LBP graded 1/10 with weakness, spasm associated fatigue, and decreased ROM.  She had no incapacitation, numbness or tingling in the lower extremities, and could stand for approximately 1 hour and walk 1-2 miles.  She also reported right sSI joint pain with a severity of 2-3/10 and weekly flares with a severity of 7-8/10.  She denied any symptoms to her hips and functionally denied any deficits.  Physical examination showed no curvature of the spine or scoliosis.  She had tenderness to her right SI joint and at L3-L5.  Lumbar spine flexion was 0-100 degrees without pain and combined ROM 215 degrees with pain at the end of all motions except flexion.  There was no loss of motion with repetition, but there was a mild increase in pain, fatigue, weakness, lack of endurance, and incoordination.   There was no tenderness of the hips at the trochanteric bursa and no warmth, redness, or swelling.  Flexion was 0-130 degrees bilaterally without pain and abduction (written as adduction) 0-45 degrees without pain.  Adduction and external rotation were normal.  She had no increase of pain or decrease in ROM with repetition. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back with associated hip pain condition 10%, coded 5243 (intervertebral disc syndrome), citing Department of Defense guidance and VASRD rating guidelines.  The VA rated the low back condition 10%, dual coded 5236-5242 (SI injury and weakness-degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined thoracolumbar ROM greater than 120 degrees, but not greater than 235 degrees.  The VA rated the hip pain separately as not service connected coded 5253 (thigh, impairment).  The panel noted the PEB listed the CI’s diagnosis as chronic LBP with associated hip pain.  However, on many occasions the clinical presentation and significant clinical findings referred to the SI joint, which IAW VASRD §4.66 (SI joint), states:  “The lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes,” rather than specific hip pathology related to the hip joint (head of the femur, acetabulum, or labrum defects), a distinct pelvic abnormality or fracture, hip musculature, tendons, ligaments, or the tensor lata fascia.  Furthermore, by the time of the VA C&P examination, 7 months after separation, the CI reported no symptoms related to the hips. Therefore, the panel determined that the associated hip pain was neither separately unfitting nor warranted a rating, but was likely related, although not definitively, to the imaging finding of a transitional L5 vertebra pseudoarticulation on the right.  The panel then determined the chronic LBP is separately unfitting. 

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) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the  physical medicine 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 VDS with incapacitating episodes which would provide for a higher rating under that formula.  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 chronic LBP with associated hip pain.  

BOARD FINDINGS:  In the matter of the chronic low back pain and associated hip pain n 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:

SAF/MRB

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Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03133.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.