RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200692 SEPARATION DATE: 20020812 BOARD DATE: 20130319 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (98J10/Electronic Intelligence Analyst), medically separated for left hip and lower extremity pain. The CI did not improve adequately with conservative treatment to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Left tarsal tunnel syndrome; bilateral posterior iliac crest syndrome; left ischial tuberosity bursitis; degenerative disk disease (DDD), L4-5, lower back pain (LBP); and bilateral patellofemoral arthrosis, hypermobile patellae conditions, identified in the rating chart below, and were also forwarded by the MEB. The Physical Evaluation Board (PEB) adjudicated the left hip and lower extremity pain condition as unfitting, rated 0% with likely application of the US Army Physical Disability Agency (USAPDA) pain policy. The remaining MEB conditions were determined to be not unfitting. The CI made no appeals, and was medically separated with a 0% disability rating. CI CONTENTION: “The conditions have worsened.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The conditions left tarsal tunnel syndrome; bilateral posterior iliac crest syndrome; left ischial tuberosity bursitis; DDD, L4-5, lower back pain; and bilateral patellofemoral arthrosis, hypermobile patellae, as implied from the contention are requested for consideration and meet the criteria prescribed in DoDI 6040.44 for Board purview and are addressed below, in addition to a review of the rating for the unfitting condition. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20020715 VA (3 Mos. Pre-Separation) – All Effective Date 20020813 Condition Code Rating Condition Code Rating Exam Left Hip and Lower Extremity Pain 5099-5003 0% See VA entry Below Left Tarsal Tunnel Syndrome Not Separately Unfitting Left Tarsal Tunnel Syndrome 5020-8525 10% 20020507 Bilateral Posterior Iliac Crest Syndrome Not Separately Unfitting Left Ischial Tuberosity Bursitis Right Ischial Tuberosity Bursitis 5019 10% 20020507 5019 10% 20020507 Left Ischial Tuberosity Bursitis Not Separately Unfitting DDD, L4-5, Low Back Pain Not Unfitting DDD, Lumbar Spine 5293 20% 20020507 Bilateral Patellofemoral Arthrosis, Hypermobile Patellae Not Unfitting Patellofemoral Arthrosis Right Knee 5299-5257 0% 20020507 .No Additional MEB/PEB Entries. 0% X 1 / Not Service-Connected x 11 20020507 Combined: 0% Combined: 40% ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which her service-incurred conditions continue to burden her. The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws (Title 38, United States Code). The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. The Board also acknowledges the CI's implied contention suggesting that ratings should have been conferred for other conditions documented at the time of separation and for conditions not diagnosed while in the service (but later determined to be service-connected by the DVA), and notes that its recommendations in that regard must comply with the same governance. Combined Left Hip and Lower Extremity Pain Rating. The PEB combined the left hip and lower extremity conditions as a single unfitting condition, coded analogously to 5003, and rated 0%, likely relying on the USAPDA pain policy for not applying separately compensable VASRD codes. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a. As elaborated below, separate compensable ratings for the left hip and the lower extremity pain were well supported by the evidence in this case. Having determined that separate ratings are warranted, however, the Board must also satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself. Not uncommonly, this approach by the PEB reflects its judgment that the constellation of conditions was unfitting and that there was no need for separate fitness adjudications, not a judgment that each condition was independently unfitting. The Board therefore exercises the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB. In this case, the left hip and lower extremity pain impairments were well supported as unfitting by evidence from the narrative summary (NARSUM) and service treatment record (STR). As to the judgment as to whether each condition was independently unfitting, neither the profile nor the commander’s statement specifically implicated the left hip or the lower extremity as the primary unfitting condition. The profile identified left tarsal tunnel syndrome, bilateral knee pain, and back pain as a L3. The limitations included no running for conditioning, no sit-ups, or push-ups, no marching, jumping, crawling, or squatting. The profile allowed lifting up to 20 pounds and walking, biking, and swimming at own pace and distance. Separating the physical impairments related to the left hip from those related to the lower extremity requires undue speculation; and, there is clinical evidence of some functional impairments referable to each joint. After deliberation, all members agreed each of the conditions, in isolation, would have rendered the CI incapable of continued service within her MOS; and, accordingly each merits a separate disability rating. Left Hip Pain Condition. The CI was seen twice in September 2001 with complaints of low back pain (LBP) yet medical care was directed primarily at her left foot pain. The evidence was absence for seeking care for LBP until January 2002 when she saw orthopedics. She reported LBP with pain in the left buttock region, was given the diagnosis of possible sciatica, and referred to Physical Medicine & Rehabilitation (PM&R). The PM&R exam demonstrated tenderness over the right and left posterior superior iliac spines, tenderness over the left ischial tuberosity and limited forward back flexion specifically cited as “placing fingertips in mid tibia before stopping due to pain in left lower lumbar region and left ischial tuberosity.” There was a negative Patrick test (provocative test for ipsilateral hip pathology or contralateral back pathology) and Milgram test (provocative test for spine disease), and a normal electromyogram (EMG) of the lower extremities. The PM&R opined, based on the physical exam, the sciatica was consistent with a left ischial tuberosity bursitis while the LBP was more consistent with bilateral posterior iliac crest syndrome. Orthopedics reevaluated the CI after the PM&R consultation and after obtaining a magnetic resonance imaging (MRI) which revealed mild DDD at L4-5 with some mild disc bulge. The orthopedic exam for the hip and the low back demonstrated normal limb length, normal posture, able to heel and toe walk, and normal neuromuscular findings of ankle dorsiflexion, ankle eversion, knee flexion, knee extension, hip adduction, or hip flexion. There was no specific goniometric detail for either the left hip or the low back. The straight leg (SLR) testing was negative for radicular symptoms. The examiner diagnosed back pain with probable component of early degenerative changes of the lumbosacral spine. At the MEB exam, the CI reported pain in the middle of the back and upon bending that radiated upward into the thoracic area and became sharp upon walking causing an inability to bend over. The MEB physical exam demonstrated mild paraspinal tenderness of the low back, normal flexion, normal lateral tilt and lateral rotation, negative SLR, negative Patrick test and normal heel-toe and tandem walk. The hip exam demonstrated tenderness to palpation of right thigh, tenderness over the left ischial tuberosity, non-compensable limitation of motion of left hip flexion and internal rotation, and normal limb length. The MEB cited the above orthopedic and PM&R LBP evaluations and listed all the diagnoses that came forth from both evaluations to include; bilateral posterior iliac crest syndrome, left ischial tuberosity bursitis, and DDD, L4-5, LBP. At the VA Compensation and Pension (C&P) exam prior to separation, the CI reported pain in her low back that radiated into her buttocks which had been diagnosed as left ischial tuberosity syndrome. She reported buttock numbness and tingling every 3 days and occasionally the pain from her low back would radiate up into her upper back. She reported taking the pain modifying medication, Ultram. The C&P exam demonstrated no new additional findings from the MEB. The Board directs attention to its rating recommendation based on the above evidence. As reiterated above the PEB bundled the left hip with the lower extremity pain condition with likely application of the pain policy and the Board agreed the left hip pain in isolation would have rendered the CI incapable of continued service. The challenge before the Board was to consider the clinical evidence as it relates to the left hip pain in order to appropriately apply the most clinically appropriate diagnostic code and rating. The Board notes the PEB adjudicated all the conditions brought forth from her evaluations for LBP to include; bilateral posterior iliac crest syndrome, left ischial tuberosity bursitis, and degenerative disc disease, L4-5, LBP, each as unfitting. The VA, however, assigned a rating for the right and left ischial tuberosity bursitis (also claimed as posterior iliac crest syndrome) and a rating for the DDD lumbar spine. It is clear the evidence supports that the PM&R and orthopedic specialists rendered several different diagnoses based on the same symptom, LBP. However, the Board notes the evidence supports primarily left hip exam findings to include tenderness of the left ischial tuberosity in both the PM&R and the MEB exam and limited left hip flexion and internal rotation in the MEB exam. Additionally, there is a non-compensable limited back flexion in the PM&R exam which radiates to the left ischial tuberosity and normal hip and back findings in the orthopedic exam. While the X-ray and MRI revealed degenerative changes of the lumbar spine, the medical member of the Board discussed that X-ray evidence in and of itself is not directly correlated to pain. Therefore, the Board agreed there is not medical certainty of any clear error in PEB diagnosis of left hip pain, which was reported as LBP, and further agreed to consider the VA’s chosen code 5019 (bursitis) as the left ischial tuberosity bursitis is the likely clinical cause of this pain. IAW VASRD §4.14 (avoidance of pyramiding) the Board agreed it could not consider all the other rendered diagnoses that came forth from her evaluations with separate multiple codes and rating pain. The VA assigned a 10% rating for the left ischial bursitis coded 5019 which defaults to the 5003 (arthritis, degenerative) code for tenderness of left hip which is inconsistent with the 5003 criteria. The 5003 criteria specifies a 10% rating is assigned whereby the evidence supports painful, non-compensable limitation of motion of a major joint or a 10% is assigned for X-ray evidence of two or more major or minor joints. None of the exams meet these criteria. There is no viable approach to a higher rating for the left hip which is countenanced by the VASRD in the absence of compensable limitation of hip ROM. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends that the left hip pain be separately adjudicated and claimed as a left ischial tuberosity bursitis disability with a rating of 0%. The Board further concludes, IAW VASRD §4.14, that there was insufficient cause to recommend a change in the PEB adjudication for the LBP or the bilateral posterior iliac crest syndrome conditions. Lower Extremity Pain Condition: During basic training the CI sought care for left foot pain after her ruck marches. She was evaluated and treated conservatively with profiling, crutches and medications for X-ray confirmed stress fracture of the 4th metatarsal. She attempted to return to full duty, 3 months later, yet continued to have pain. A bone scan, in December 2001, confirmed the presence of a stress reaction of either the fourth or the 5th metatarsal. Over the next 3 months she underwent a podiatry, PM&R and orthopedic evaluations and all specialties diagnosised tarsal tunnel syndrome of the left foot based on their exam findings with a documented normal EMG. At the MEB exam, the CI reported constant, numbing, throbbing pain from the left foot up to the upper leg with a 7 of 10 in intensity. The pain worsened with standing, walking, wearing high-heel shoes, or with any increased physical activity and was minimally relieved with stretching exercises. The MEB physical exam demonstrated no ankle swelling, normal bilateral ankle range-of-motion (ROM), and normal heel-toe and tandem walk. X-rays and MRI of the left foot and ankle were unremarkable. At the VA Compensation and Pension (C&P) exam prior to separation, the CI reported after walking 45 minutes she had to sit down and rest for an hour, after standing 10 to 15 minutes she started to have pain that would last 15 minutes, and night pain when she first put her feet up. She reported some relief with the pain modifying medication, Ultram. The C&P exam additionally documented pes cavus, tenderness with palpation at the left fifth metatarsal, normal neuromuscular findings of the lower extremity and otherwise had the same findings of the MEB exam. The Board directs attention to its rating recommendation based on the above evidence. This rating includes consideration of functional loss lAW VASRD §4.10 (functional impairment), §4.40 (functional loss), §4.45 (DeLuca), and §4.59 (painful motion). As reiterated above the PEB bundled the left hip with the lower extremity pain condition and the Board agreed the lower extremity pain in isolation would have rendered the CI incapable of continued service. The challenge before the Board was to consider the clinical evidence as it relates to the lower extremity in order to appropriately apply the most clinically appropriate diagnostic code and subsequent rating. The Board discussed the stress fracture of the metatarsal and that with treatment the evidence supports this had resolved with documented normal X-rays at the time of the MEB. The Board notes all the specialties consistently diagnosed her with tarsal tunnel syndrome. Additionally, the VA coded analogous to 8525 (Paralysis of posterior tibial nerve (tarsal tunnel). Therefore the Board agreed to consider the VA’s chosen code as the most clinically appropriate for its permanent rating recommendation. The VA assigned a 10% rating for history of pain and subjective complaint of pain which is consistent IAW criteria under §4.124a—Schedule of ratings–neurological conditions and convulsive disorders and likely with consideration of either VASRD §4.10, functional impairment or VASRD §4.40, functional loss. The Board agreed the evidence supports a 10% rating invoking VASRD §4.40 for the functional limitation of the inability to stand for more than 10 minutes before the onset of pain. The Board further agreed there is no viable approach to a higher rating for the lower extremity pain which is countenanced by the VASRD in the absence of limitation of motion of the ankle, incapacitating episodes or incomplete paralysis of foot movements which are severe. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends that the lower extremity pain be separately adjudicated and claimed as a left tarsal tunnel disability with a rating of 10%. Contended PEB Conditions. The remaining contended conditions adjudicated as not unfitting by the PEB was bilateral patellofemoral arthrosis, hypermobile patellae. The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. This condition was profiled; implicated in the commander’s statement; and, judged to fail retention standards. All were reviewed by the action officer and considered by the Board. There was no indication from the record that any of this condition significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and, therefore, no additional disability ratings can be recommended. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. As discussed above, PEB reliance on the USAPDA pain policy for rating left hip and lower extremity pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the left hip pain condition, the Board unanimously recommends to claim it as left ischial tuberosity bursitis with a disability rating of 0%, coded 5019-5003 IAW VASRD §4.71a. In the matter of the lower extremity pain condition, the Board unanimously recommends to claim it as a left tarsal tunnel syndrome with a disability rating of 10%, coded 5020-8525 IAW VASRD §4.71a-§4.124a. In the matter of the contended LBP, the bilateral posterior iliac crest syndrome, and the bilateral patellofemoral arthrosis, hypermobile patellae conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation: UNFITTING CONDITION VASRD CODE RATING Left Hip Pain claimed as Left Ischial Tuberosity Bursitis 5019-5003 0% Lower Extremity Pain claimed as Left Tarsal Tunnel Syndrome 5020-8525 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120603, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxx, AR20130007713 (PD201200692) 1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)