[AR Number], XXXXXXXXXX

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

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.

,		

			      

Enclosure

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03258
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Operating Room Technician, medically separated for “chronic low back pain” and “chronic bilateral hip pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  In addition to the hip and back conditions, the CI requested review of any other conditions which currently affect her.  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 - 20060816	VARD - 20070118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Lumbar Strain	5237	10%	20060907	
Chronic Bilateral Hip Pain	5099-5021	0%	Right Hip Strain 	5251	10%	20060907	
			Left Hip Strain 	5251	10%	20060907	
Migraine Headaches	Not Unfitting	Migraine Headache	8100	0%	20060907	
PTSD	Not Unfitting	PTSD	9411	10%	20060907	
Polycystic Ovary Syndrome	Not Unfitting	Polycystic Ovary (Stein-Leventhal Syndrome)	7615	0%	20060907	
Hidradenitis Suppurativa	Not Unfitting	Residual Scar S/P Wide Local Excision of Left Groin Hidradenitis Suppurativa	7804	10%	20060907	
		Residual Scar S/P Wide Local Excision of Right Groin Hidradenitis Suppurativa	7804	10%	20060907	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began towards the end of basic training in association with bilateral hip pain.  Symptoms were exacerbated in January 2005 after doing a PT test, when she slipped and fell on a concrete slab.  An MRI of the lumbosacral spine in May 2006 was normal.  

The 11 July 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of worsening back pain affecting her ability to sit in a single position for extended amounts of time. Physical examination showed tenderness.  Range of motion (ROM) testing by physical therapy showed unlimited flexion (normal 90) and 30 degrees of extension (normal) with pain on passive extension, bilateral flexion and left rotation.  Muscle strength, reflexes and sensation were normal.  

The 14 August 2006 orthopedic MEB addendum provided clarification of the CI’s conditions.  The diagnosis was “piriformis muscle syndrome,” which was defined as “hyperactivity of the piriformis muscle, possibly causing some compression and irritation of the sciatic nerve.”  The piriformis muscle syndrome was the likely cause of all the symptomatology.  

At the 7 September 2006 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI complained of lumbar spine pain and mild sciatica in the left leg.  Physical examination showed the CI could walk adequately without any difficulties, but the gait was slightly antalgic to her left side due to the back and left hip problems.  There was mild to moderate manifestation of pain (tenderness), spasm and stiffness on her lumbar spine.  The ROM study showed flexion of 80 degrees and extension of 20 degrees with pain and stiffness.  There was no active sciatica to the left lower extremity with leg raising, flexion or extension of the lumbar spine.  There was no evidence of sciatica to the left lower leg and she had more spasms on the left leg.  With repetitive use and motion of the spine, the examiner opined she would develop mild physical limitation mostly manifested by pain.  During flare-ups physical impairment would be mild to moderate.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing tenderness.  The VA also rated the back condition 10%, coded 5237, based on the C&P examination, citing limited flexion due to pain.   The panel considered the findings of both the NARSUM and the C&P examination were similar but the NARSUM examination did not address gait, and the C&P examination showed that, “the CI walked adequately without any difficulties and physical limitation was minimal.”  The NARSUM examination showed tenderness over the lumbar processes and the C&P examination showed painful motion, each finding also resulting in 10% disability.  Neither examination showed evidence of lumbar spasm or guarding resulting in an antalgic gait to warrant a higher 20% rating.  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 back condition.  

Chronic Bilateral Hip Pain. The PEB combined the right and left hip conditions under a single disability rating, coded 5099-5021 and rated 0%.  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 right and left hip conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the STR and MEB NARSUM, the CI’s bilateral hip condition began in 2002 after a road march.  Pain escalated after the fall described above.  The CI had surgery in August 2005 on her inner hip and groin region of both legs due to infectious skin lesions.  Bone imaging in April 2006 showed mild diffuse increased uptake in the left femoral neck and focal increased uptake in the right tibial tubercle read as stress reaction in the left hip and in the right tibial tubercle.  An MRI in May 2006 showed no evidence of fracture, dislocation, focal osteoporosis, periosteal reaction or lytic lesions bilaterally.  Orthopedics noted in June 2006 that pain in both hips had become constant.  During the 4 July 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported a swollen and painful left hip.  Physical examination revealed tenderness in the left hip region.  

The MEB NARSUM examination noted complaints of bilateral hip pain with worsening left hip pain aggravated by physical activity.  Physical examination showed tenderness over both femoral triangles, but ROM was normal without pain and there was no instability.  There was left trochanteric bursa tenderness.  The ROM study by physical therapy showed right hip flexion to 110 degrees (normal 125), extension to 10 degrees (normal 20), abduction to 34 degrees (normal 45) external rotation to 12 degrees (normal 45) and left hip flexion to 108 degrees, extension to 3 degrees, abduction to 20 degrees and external rotation to 15 degrees.  

At the C&P examination, 1 month before separation, the CI reported bilateral hip pain and spasm, but an orthopedics consultation indicated nothing was wrong with her hips other than piriformis muscle syndrome.  The CI also reported moderate relief of pain and spasm with physical therapy.  Physical examination showed flexion of 115 degrees bilaterally, extension of 5 degrees with pain and stiffness, abduction of 45 degrees and external rotation of 45 degrees.  There was pain with extension and stiffness of her hips bilaterally.  There was also mild pain with palpation of the iliac crests.  The examiner opined the CI would have mild physical impairment and pain during flare-ups and with repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral hip condition 0%, analogously coded 5099-5021 (myositis), citing normal ROM of the affected parts.  The VA rated the right and the left hip conditions 10% each, coded 5251 (thigh, limitation of extension to 5 degrees), based on the C&P examination, citing limited, painful motion of the right and the left hips.  

In this case, the STR evidence indicated both hips were painful but there are repeated references (STR, NARSUM, ortho) to left hip pain, especially over the trochanteric bursa.  Only the left hip was profiled, but the commander’s statement implicated both hips and noted an additional injury to the left hip in February 2006.  Both the NARSUM and the C&P examinations showed findings that were essentially the same in both hips.  Imaging most proximal to separation was normal in both hips.  The panel concluded the preponderance of evidence showed the right and left hip conditions were reasonably considered separately unfitting.  

The C&P examination was closer to the date of separation, and showed evidence of pain on motion, bilaterally, thus warranting a 10% disability rating IAW §4.59 (painful motion) for each hip.  However, the panel minority placed more probative value on the NARSUM examination which was felt to be more thorough and showed no evidence of bilateral painful motion.  The minority voter accorded a 10% rating for the left hip condition and 0% rating for the right hip condition under code 5251.  The panel majority also noted the C&P examination showed extension to 5 degrees bilaterally, which would also warrant a 10% rating bilaterally under the 5251 code, but that offered no rating advantage to the coding for painful motion.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a 10% rating for the left hip condition, coded 5099-5021, and a 10% rating for the right hip, coded 5099-5021.  

Contended PEB Conditions:  Migraine Headaches, PTSD, Polycystic Ovary Syndrome and Hidradenitis Suppurativa.  The panel’s main charge is to assess the fairness of the PEB determinations that the contended conditions were not unfitting.  In regards to the PTSD, the CI complained of nightmares, insomnia, anger and irritability and was diagnosed with PTSD and treated with medication and counseling.  The NARSUM examination indicated the CI, by her own report, was in full remission.  The VA C&P examination noted the CI’s report that her PTSD was stabilized.  None of the contended conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  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 there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.   

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  In the matter of the right hip condition, the panel majority recommends a disability rating of 10%, coded 5099-5021 IAW VASRD §4.71.  In the matter of the left hip condition, the panel recommends a disability rating of 10%, coded 5099-5021 IAW VASRD §4.71.  The single voter for dissent recommends no change to the right hip condition, but does not elect to submit a minority opinion.  In the matter of the contended migraine headaches, PTSD, polycystic ovary syndrome and hidradenitis suppurativa, 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5299-5237	10%	
Right Hip Pain	5099-5021	10%	
Left Hip Pain	5099-5021	10%	
COMBINED	30%	

The following documentary evidence was considered: