RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD1201974
BRANCH OF SERVICE:  Army	BOARD DATE:  20130426
SEPARATION DATE:  20030701

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (92A/Automated Logistics Specialist) medically separated for pain in the left hip and low back.  The CI first began experiencing pain in his left hip in 2001 while running for exercise, then exacerbated this condition when he fell on ice later that same year.  He also began to complain about low back pain (LBP).  Despite testing, medication, and physical therapy these left hip and back conditions could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards, so the CI was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The hip and low back conditions, characterized as “chronic left hip pain” and “chronic low back pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “chronic pain, left hip and low back, rated as slight/frequent” as unfitting and rated 10% IAW US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated with a 10% disability rating.

CI CONTENTION:  “Chronic Pain, Left Hip & Low Back (MEBD 1, 2, & NARSUM”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The Service rating for the unfitting left hip and low back conditions is addressed below.  Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review remain eligible for consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service PEB – Dated 20030415	VA – based on Service Treatment Records (STRs)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Hip and Low Back, Rated as Slight/Frequent	5099-5003	10%	Lumbosacral Myofascial Dysfunction	5237	10%	STR	
			Left Lateral Cutaneous Neuropathy	8529	10%	20040309	
No Additional MEB/PEB Entries	Other x 5	STR	
Combined:  10%	Combined:  20%	
Derived from VA Rating Decision (VARD), dated 20040830 (most proximate to the date of separation)

ANALYSIS SUMMARY:  The PEB combined the left hip and low back pain (LBP) conditions as a single unfitting condition rated as 5099-5003 (analogous to arthritis) at 10%.  The PEB relied 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 rating guidelines.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself.  Thus, the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that recommendations may not produce a lower combined rating than the PEB.

Chronic Left Hip Pain .  The narrative summary (NARSUM) notes the CI began with left hip pain while running in October 2001, aggravated by a fall on the ice a couple months later.  He had extensive evaluation by multiple specialists.  X-rays bone scan, electromyography (EMG)/nerve conduction studies (NCS), and left hip magnetic resonance imaging (MRI) were normal.  The physician who conducted the EMG/NCV stated that clinically the CI had lateral femoral cutaneous nerve neuropathy.  Orthopedic evaluation found evidence of tendon inflammation on X-ray, but MRI was normal.  At the MEB exam, 20 February 2003, approximately 4 months prior to separation, the CI reported being unable to run, jump do sit-ups or push-ups, or stand for long periods.  The MEB exam showed decreased ROM and tenderness to palpation (TTP) of the left hip.  Muscle tone was good.  Bilateral lower extremity strength and sensation was normal.  There were no neurological abnormalities noted.

At the VA Compensation and Pension (C&P) exam on 9 March 2004, approximately 8 months after separation, the CI reported left inguinal pain that extended from the left lateral hip to the groin, described as dull, but sometimes sharp, stabbing pain in the groin.  He reported intermittent paresthesias and decreased sensation of the left lateral thigh, aggravated by prolonged standing or sitting.  The VA exam showed normal gait, heel, and toe walking.  There was no TTP of the left hip, but range-of-motion (ROM) was decreased and groin pain was reproduced with hip flexion from 55-60 degrees; external rotation 0-50 degrees; internal rotation 0-40 degrees.  There were no DeLuca criteria.  There was TTP over the inguinal canal without evidence of hernia or other groin abnormality.  The examiner’s impression was chronic left groin pain associated with lateral femoral cutaneous nerve neuropathy.  By specific request the examiner also gave the opinion that the CI’s claimed left hip pain was not likely due to his hip, but rather injury involving the lateral femoral cutaneous nerve and its branches.

Low back pain condition.  The NARSUM noted that the CI began with left hip pain after running in October 2001.  His symptoms included paresthesias of the upper outer left thigh and pain that radiated into the groin, and back.  Service treatment records (STRs) indicate few visits mentioning LBP.  The lumbar spine was evaluated as a source of the pain.  Left lower extremity EMG/NCV was normal without any evidence of a radiculopathy of the left leg.  Lumbar MRI 
12 December 2002 showed degenerative changes and mild foraminal stenosis.  A neurosurgical consult diagnosed lumbosacral myofascial dysfunction.  The MEB physical exam noted a normal gait, station, strength, and sensation.  ROM was normal with the exception of approximately 80 degrees of flexion (normal 90 degrees), also described as the CI could reach approximately 20 cm (8 inches) from his fingers to the floor.  At the C&P exam the lumbar spine was not addressed.  The VA rated the LBP condition based on service treatment records as 5237 at 10%.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB bundled the chronic left hip and LBP conditions as one unfitting condition and rated as 5099-5003 (analogous to degenerative arthritis) at 10%.  The Board first undertook to unbundle the left hip and the LBP conditions.  The permanent profile listed left hip pain and chronic LBP.  The commander’s statement noted chronic groin pain, but indicated work restrictions that impaired the CI’s duty performance which included activities such as lifting and carrying that would relate to both conditions.  The majority of notes in the STR address the left hip pain, noted to radiate at times to the back.  However, a specialist did diagnose a soft tissue LBP condition 1 October 2002 as separate from the left hip pain  The Board agreed that based on the evidence in the record both the left hip and LBP conditions were reasonably considered to be separately unfitting conditions at the time of separation.

Chronic left hip pain condition:  the VA rated the left hip pain condition as 8529 (neuropathy, external cutaneous nerve of the thigh) at 10%.  The Board deliberated coding the left hip pain IAW §4.124a (Schedule of ratings- neurological conditions and convulsive disorders) or §4.71a (Schedule of ratings-musculoskeletal system).  The CI’s left hip disability was pain, without muscle weakness, instability or reflex abnormalities.  The highest achievable rating under 8529 is 10% for severe neuropathy of the external cutaneous nerve).  The Board considered coding as 5252 (limited thigh flexion) or 5253 (limited abduction, adduction or rotation) and found 10% to be the highest rating achievable for decreased left hip motion IAW §4.59 for painful motion.  Therefore, the codes are equivalent and the Board chose coding as 5252.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left hip pain condition.

Chronic low back pain condition: post separation the VA rated the LBP condition as 5237 (lumbosacral strain) at 10% according to the current spine disability rating guidelines (in effect after 26 September 2003).  The Board must use the spine disability rating guidelines in effect at the time of separation.  The MEB exam indicated slight decrease flexion, otherwise normal lumbar spine exam and the VA provided a rating based on STRs. There was no evidence of incapacitating episodes in the record.  In accordance with VA spine rating guidelines in effect on the date of separation the Board considered coding as 5292 (limitation lumbar motion) or 5295 (lumbosacral strain).  There was no documentation of characteristic pain on motion or muscle spasm, therefore the Board opined that the CI’s LBP condition was best rated as 5292 for slight limitation of flexion at 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the LBP condition coded as 5292.

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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the chronic pain, left hip and low back condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic left hip pain condition, the Board by a 2:1 vote recommends a disability rating of 10%, coded 5252 IAW VASRD §4.71a.  In the matter of the chronic LBP condition, the Board by a 2:1 vote recommends a disability rating of 10%, coded 5292 IAW VASRD §4.71a.  The single voter for dissent (who recommended no characterization of the PEB adjudication) did not elect to submit a minority opinion.  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 his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Left Hip Pain Condition	5252	10%	
Chronic Low Back Pain Condition	5292	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120619, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	Physical Disability Board of Review

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for AR20130010299 (PD201201974)

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 20% 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						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA