RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-05206
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070309

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Financial Management and Comptroller Craftsman, medically separated for “degenerative disc disease [DDD] leading to chronic low back pain and secondary hip/groin pain” with a disability rating of 10%.  

CI CONTENTION:  Review of all conditions requested.  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 - 20070119	VARD - 20070530	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain and Secondary Hip/Groin Pain	5243	10%	Chronic Lumbar Strain	5237	0%	20070209	
			Flexor Tendonitis, Right Hip	5251-5024	0%	20070209	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain and Secondary Hip/Groin Pain.  The PEB combined the low back pain and hip groin pain as a single unfitting condition coded 5243, intervertebral disc syndrome 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 or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of 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 Board 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 back and bilateral hip conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI experienced an onset of low back pain with repetitive lifting in 2005 that was exacerbated by a fall in January 2006.  Imaging (MRI) demonstrated DDD at L3-4 and L5-S1 without neural compromise.  There was no radiculopathy or neurological deficits and surgery was not recommended.  The back condition emerged earlier than the hip/groin complaints, and, although it was not entirely clear, it appeared that the MEB was initially precipitated by the back pain alone.  There were several STR provider entries that documented grossly normal thoracolumbar range of motion (ROM) without note of painful motion.  There was STR documentation of a normal gait and spinal contour, with no contrary evidence or indication of more significant ROM limitation (except as noted below).

The 1 November 2006 MEB NARSUM examination, 4 months prior to separation, documented persistent back pain rated 1-2/10 at rest with exacerbations to 5/10 by exercise, bending and lifting.  The examiner stated that the combination of “lumbar/hip/groin pain” prohibited running, lifting over 20 pounds, and prolonged sitting or standing.  The physical examination recorded a normal spinal contour and neurological findings with “full flexion and extension” and no note of painful motion, gait disturbance, tenderness, or spasm.  A physical therapy (PT) entry on 14 November 2006 documented flexion to 75 degrees (normal 90), extension to 15 degrees (normal 30) and bilateral rotation to 10 degrees (normal 30), specifying painful motion.  Neither the profile (L4) nor commander’s performance statement were probative to separate unfitness of the lumbar spine or either hip.

At the 9 February 2007 VA Compensation and Pension (C&P) examination, one month before separation, the CI reported constant low back pain rated 6/10 rendering her “unable to run or do lifting.”  The physical examination recorded a normal gait, spinal contour and neurological findings without note of tenderness or spasm.  Measured ROM was normal in all planes (flexion to 90 degrees and combined ROM of 240 degrees), specifying no painful motion or ROM degradation with repetition.

Directing attention to its recommendations, the panel first considered if the back condition was reasonably justified as separately unfitting for independent rating.  Given its condition nomenclature and overall coding as a spinal condition, the PEB implied that it considered the lumbar disc disease to be the primary unfitting condition.  The STR suggested that MEB referral was primarily for back pain.  The panel thus agreed that, although it may have been the overall combined effect of the lumbar and hip/groin conditions that rendered the CI unfit, more likely than not the lumbar condition would have resulted in medical separation independently of the hip/groin limitations.  Having agreed that separate rating was indicated, the panel turned to deliberation of the appropriate coding and rating recommendation.  The VA rated the back condition 0%, coded 5237 (lumbar strain), citing the absence of any compensable criteria from the C&P examination.  There was no evidence for ROM limitation nor abnormal gait or spinal contour that would justify a rating higher than 10% under the VASRD §4.71a spine formula.  Based on its code choice, it appears that the PEB conceded a minimum 10% rating for the back condition based on the service evidence.  Taking into consideration the VA C&P evidence, more temporally probative to separation, it could be argued there was unsatisfactory evidence of painful motion or other VASRD criterion in support of the minimum 10% rating.  Members agreed, however, that reasonable doubt favored concession of a 10% rating (via painful motion per the service PT examination, or functional loss with pain on use); also considering that, as above, the PEB’s 10% rating is obligatory unless an additional rating contributes to the combined rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends the back condition as separately unfitting with a 10% rating under code 5242 (degenerative arthritis of the spine).  

Hip/Groin Pain.  A complaint of bilateral hip pain emerged in PT notes while the CI was being treated for back pain.  It was later attributed to the January 2006 fall implicated above with the back pain.  A groin component was variously described with a suspected diagnosis of groin strain.  It was clear from STR clinical entries that the right hip was more symptomatic than the left, and many entries were directed solely at right hip pain.  Only the right hip was imaged by the service (X-rays, MRI and arthrogram) and all studies were normal.  The VA obtained bilateral X-rays which were also normal.  Neurosurgery opined that the hip pain was possibly a result of nerve root irritation from DDD, although no clear cause-and-effect relationship or specific etiology for the hip/groin pain was established in STR clinical entries.  Several STR provider entries documented grossly normal bilateral hip ROM, with no evidence to the contrary, and without specific notation of painful motion.  There was STR confirmation of a normal gait as above and no evidence for any additional VASRD-ratable findings.  

The NARSUM did not differentiate right versus left severity of “bilateral hip pain with groin radiation” and relied on the tentative neurosurgeon opinion (above) that it was associated with lumbar disc disease.  The pain was rated “4/10 at rest, 6/10 during prolonged standing or sitting.”  Along with the back condition as above, the NARSUM also implicated hip/groin pain with restrictions of heavy lifting and running.  The physical examination recorded normal joint strength, no deformity or crepitus (no note of tenderness), and “full flexion and extension/internal and external rotation.”  There was no STR evidence for formal measurements of hip ROM.  As previously noted, the commander’s statement and profile were not probative for determination of separate unfitness (including right versus left hip).  

The pre-separation C&P examination (same as for lumbar rating) addressed only right hip pain with no claim for, or documentation of, left hip pain.  The VA examiner opined that the concurrent complaint of groin pain was not a separate condition.  The right hip pain was reported as constant and rated 5-6/10, and the only specified functional limitation was an inability to run.  The physical examination recorded anterior tenderness of the right hip (superior iliac spine) with otherwise normal findings (to include normal gait).  Measured ROM was normal in all six planes, specifying no painful motion or ROM degradation with repetition.  The VA examiner made the specific diagnosis of “chronic right hip flexor tendonitis, which is consistent with the examination findings and normal X-rays.”

Directing attention to its recommendations, the panel first considered if the bilateral hip/groin condition was reasonably justified as separately unfitting.  The panel agreed that, although it may have been unfitting solely by combined effect with the back condition, the hip/groin pain made a significant contribution to the CI’s functional limitations for military duty; and, that it would be overly speculative to conclude that it would not have precluded continued military service in itself.  Therefore, members agreed that the hip/groin condition was fairly conceded as separately unfitting and ratable, but that only the right hip could be reasonably justified as unfitting.  This was because of the significantly greater severity of the right hip in STR provider entries and the fact that, by the time of separation, only the right hip was brought to the VA’s attention.  That indicated that the left hip/groin pain was resolving and would not have, in itself, resulted in medical separation. 
  
Having agreed that separate rating was indicated for the right hip, the panel turned to deliberation of the appropriate coding and rating recommendation.  The VA rated the right hip 0%, dual coded 5251-5024 (limitation of hip extension rated as tenosynovitis), citing the absence of any compensable criteria from the C&P examination.  The panel agreed that there was no ratable distinction between the hip and groin pain that could be clinically identified.  There was no minimum compensable ROM limitation under any applicable codes (5251, 5252 or 5253) or evidence for any ratable criterion under any other code, even analogously.  Members further agreed that there was no satisfactory evidence of painful motion to support a minimum 10% rating; thus, no rating greater than 0% could be justified based on the available evidence probative to the time of separation.  After due deliberation, considering all the evidence and with deference to reasonable doubt, the panel recommends a 0% rating for the right hip/groin condition coded 5099-5024 (analogous to tenosynovitis) as separately unfitting; and, concluded that the left hip/groin condition was not reasonably justified as separately unfitting.

BOARD FINDINGS:  In the matter of the PEB-combined lumbar spine and associated bilateral hip/groin conditions, the panel recommends that it be rated for separate conditions as follows:  a separately unfitting lumbar spine condition rated 10% under code 5242 IAW VASRD §4.71a; a separately unfitting right hip/groin condition rated 0% under code 5099-5024 IAW VASRD §4.71a; and, a left hip/groin condition determined to be not unfitting and not subject to disability rating.  There are no other conditions within the panel’s scope of review for consideration.  As the proposed new combined disability rating results in no change to the combined disability rating, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-05206.

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.