RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:                                 BRANCH OF SERVICE:  army
CASE  NUMBER:   PD1100493                                  SEPARATION  DATE:
20050104
BOARD DATE:  20120109


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered individual (CI) was an active duty member, SGT/E-
5 (25Q20/Multichannel Transmission Systems  Operator/Maintainer),  medically
separated for left sacroiliac (SI) joint dysfunction  with  left  hip  pain.
The CI’s low back pain with radiation to his left leg  began  after  lifting
equipment in 2003 (he  lifted  a  metal  table  top  over  his  head).   MRI
revealed two-level degenerative disc disease (DDD) with L4-5  impinging  the
central canal.  His treatment included  medications  (including  narcotics),
physical  therapy  (including  TENS),  chiropractic  manipulation,  epidural
steroid injections, and surgery (L4-S1 fusion in  February  2004).   He  did
not respond adequately to treatment and was unable  to  perform  within  his
Military Occupational Specialty (MOS) or meet  physical  fitness  standards.
He was issued a permanent  P3  and  underwent  a  Medical  Evaluation  Board
(MEB).  Left sacroiliac joint dysfunction and left hip pain  were  forwarded
to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR  40-
501.   No  other  conditions  appeared  on  the  MEB’s  submission.    Other
conditions included in the  Disability  Evaluation  System  (DES)  file  are
discussed below.  The Informal PEB (IPEB) combined the two  conditions,  and
adjudicated the  left  sacroiliac  joint  dysfunction  with  left  hip  pain
condition as unfitting, rated 10%, with likely application of  the  US  Army
Physical Disability Agency (USAPDA) pain policy and/or AR 635-40 (B.24  f.).
 The CI did not appeal for a formal PEB, and was medically separated with  a
10% disability rating.


CI  CONTENTION:   “Not  all  medical  reasons  was  [sic]   considered   for
disability.   Also  VA  disability  rating  was  not  considered  for   Army
disability rating.  Original rating was told to me by a  E-7  sergeant  that
if I challenged the rating the Army gave me then I would lose the  10%  that
was granted to me.  Original rating paperwork [is] on file with  the  VA  in
Bonham Texas.”  He elaborates no specific contentions  regarding  rating  or
coding and mentions  no  additionally  contended  conditions.   All  service
conditions are reviewed by the Board for  their  potential  contribution  to
its rating recommendations.


RATING COMPARISON:

|Service IPEB – Dated 20041022  |VA (~1 Mo. After Separation) – All        |
|                               |Effective Date 20050105                   |
|Condition                      |Code                              |Rating |
|Combined:  10%                 |Combined:  40%                            |


ANALYSIS SUMMARY:  The Board acknowledges the CI’s contention that  suggests
service ratings should have been conferred for other  conditions  documented
at the time of separation.  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.  While  the  DES  considers
all of the service member's medical conditions,  compensation  can  only  be
offered for those medical conditions  that  cut  short  a  service  member’s
career, and then only to the degree of  severity  present  at  the  time  of
final disposition.  However  the  Department  of  Veterans’  Affairs  (DVA),
operating under a different set of laws (Title 38, United States  Code),  is
empowered  to  compensate  all   service   connected   conditions   and   to
periodically reevaluate said conditions for the  purpose  of  adjusting  the
Veteran’s disability rating should his degree of impairment vary over time.

The PEB combined lumbosacral and left hip conditions as a  single  unfitting
condition, coded as 5236 (sacroiliac injury and weakness),  and  rated  10%.
The PEB may have relied on AR  635-40  (B.24  f.)  and/or  the  USAPDA  pain
policy for not applying separately compensable  VASRD  codes.   However,  it
was most likely  that  the  left  hip  pain  was  radicular  pain  from  the
lumbosacral condition.  The Board must apply separate codes and  ratings  in
its recommendations if compensable ratings for each condition  are  achieved
IAW VASRD §4.71a.  If the Board judges that two  or  more  separate  ratings
are warranted in such cases, it  must  satisfy  the  requirement  that  each
“unbundled” condition was unfitting in and of itself.  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.   Thus,  the
Board must exercise 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.

Left SI Joint Dysfunction.  The Board first  considered  if  left  SI  joint
dysfunction, having been de-coupled  from  the  combined  PEB  adjudication,
remained  independently  unfitting  as  established  above.   The  SI  joint
dysfunction  was  apparently  related  and  almost  certainly  served  as  a
surrogate for the CI’s spine DDD and spine surgery (L4-S1 fusion  11  months
pre-separation), as pain in the left hip and SI joint  area  were  the  CI’s
predominate symptoms.  Both the permanent profile and commander’s  statement
directly implicate the lumbar spine or “back”  injury  or  surgery  (to  the
neglect of any SI joint involvement).  IAW VASRD  4.71a,  the  SI  joint  is
evaluated under the General Rating Formula for Diseases and Injuries of  the
Spine, which considers the total disability of the thoracolumbar  spine,  so
there is no need to attempt to apportion symptoms related to  the  SI  joint
versus  those  related  to  the  lumbar  spine.   All  members  agreed  that
thoracolumbar spine/left SI joint dysfunction,  as  an  isolated  condition,
would have rendered the CI incapable of continued service  within  his  MOS,
and accordingly merits a separate service rating.

There were four lumbosacral spine exams, including two complete  goniometric
range-of-motion (ROM) evaluations, in evidence which the  Board  weighed  in
arriving at its rating recommendation.  All of these  exams  are  summarized
in the chart below.


|Goniometric  |MEB (PT) ~ 7 |NARSUM ~ 3 Mo.|Pain Mgmt ~ 2 |VA C&P ~ 1 Mo. |
|ROM -        |Mo. Pre-Sep  |Pre-Sep       |mos Pre-Sep   |Pre-Sep        |
|Thoracolumbar|             |              |              |               |
|Ext (0-30)   |(20⁰,20⁰,20⁰)|              |10⁰           |15⁰            |
|             |20⁰          |              |              |               |
|R Lat Flex   |(35⁰,40⁰,35⁰)|              |              |25⁰            |
|(0-30)       |30⁰          |              |              |               |
|L Lat Flex   |(40⁰,40⁰,    |              |              |25⁰            |
|0-30)        |40⁰) 30⁰     |              |              |               |
|R Rotation   |(35⁰,38⁰,    |              |              |30⁰            |
|(0-30)       |40⁰) 30⁰     |              |              |               |
|L Rotation   |(25⁰,25⁰,30⁰)|              |              |30⁰            |
|(0-30)       |25⁰          |              |              |               |
|COMBINED     |205⁰         |              |              |165⁰           |
|(240)        |             |              |              |               |
|Comment:     |Limited by   |TTP with axial|Antalgic gait,|Painful motion,|
|Surgery ~ 11 |pain and     |compression of|TTP, pos facet|diminished     |
|Mo. Pre-Sep  |represents   |left SI joint,|load L>R,     |sensory (LT)   |
|             |pt’s         |no motor or   |motor 5/5,    |left hip,      |
|             |willingness  |sensory       |painful on    |normal posture |
|             |to move      |deficits,     |heels & toes, |& gait w/o     |
|             |through pain;|DTR’s normal, |DTR’s (knees  |assistive      |
|             |[4 mos post  |SLR neg bilat,|+1 bilat.,    |device, motor  |
|             |op]          |pos Patrick’s,|ankle absent  |normal, no     |
|             |             |pos Gaenslen’s|on left), pos |atrophy,       |
|             |             |on left, pain |Patrick’s, pos|reflexes + 2 at|
|             |             |w/ internal   |Gaenslen’s,   |knees bilat,   |
|             |             |rotation of   |neg SLR       |repeated and   |
|             |             |left hip      |              |resisted motion|
|             |             |              |              |did not further|
|             |             |              |              |limit ROM or   |
|             |             |              |              |function, SLR  |
|             |             |              |              |neg, able to   |
|             |             |              |              |heel –toe walk |
|             |             |              |              |w/o difficulty,|
|             |             |              |              |Waddell’s neg  |
|§4.71a Rating|10%          |N/A           |20%           |20%            |

ROMs recorded by physical therapy seven months pre-separation  (four  months
post-operative) revealed limitations and  painful  motion  meeting  the  10%
criteria IAW the General Rating Formula for Diseases  and  Injuries  of  the
Spine, VASRD §4.71a.  The MEB DD Form 2808, six months  pre-separation,  did
not provide ROMs but noted  a  healed  lumbar  scar  with  some  tenderness,
positive straight leg raises at 70° on the right and 45° on  the  left,  and
the CI was able to heel- and  toe-walk.   The  narrative  summary  (NARSUM),
three months pre-separation, reported tenderness  to  palpation  with  axial
compression of the left SI joint, positive tests for  SI  joint  dysfunction
(Patrick’s and Gaenslen’s tests), and pain with  internal  rotation  of  the
left hip (see hip discussion below).  The exam was  otherwise  normal,  with
no motor or sensory deficits, normal reflexes,  and  negative  straight  leg
raises bilaterally.  No post-operative MRI  was  of  record.   Lumbar  spine
radiographs revealed intact implants and good  intervertebral  fusion  mass.
An outpatient clinical entry three months pre-separation, the day  prior  to
the IPEB (not included in above chart for brevity), reported the CI fell  in
his home, reinjuring his back, exacerbating his pain,  and  causing  reduced
ROMs in all planes (no  quantitative  measurements).   An  outpatient  entry
from pain management two months pre-separation (10  days  after  the  IPEB),
reported significantly reduced flexion and extension  (flexion  meeting  the
20% criteria under the General Rating Formula), antalgic  gait,  tenderness,
positive facet loading test (left greater than  right),  positive  Patrick’s
and Gaenslen’s tests (for SI joint dysfunction), painful  walking  on  heels
and toes, and abnormal reflexes (knee reflexes  reduced  bilaterally,  ankle
reflex absent on left).  Normal findings included 5/5  motor,  and  negative
straight leg raises.  The new diagnosis was failed back syndrome and the  CI
was continued on narcotic pain management.

The VA exam  one  month  pre-separation,  reported  similarly  reduced  ROMS
(meeting the 20% criteria), painful  motion,  and  diminished  sensation  to
light touch over left hip.  The remainder  of  the  exam  was  normal,  with
normal posture and gait without assistive device, normal motor function,  no
atrophy, reflexes normal (+2) at knees bilaterally,  and  negative  straight
leg raises.  The CI was able to heel-and-toe walk  without  difficulty,  and
repeated and resisted motion did not further limit  ROM  or  function.   The
examiner noted the absence of Waddell’s  or  other  non-organic  signs.   In
addition to the lumbar spine injury status post discectomy  and  fusion  L4-
S1, the examiner diagnosed “residue of nerve  injury  of  L5  and  S1,  most
likely secondary to the lumbar spine injury.”

There  were  no  reports  of  incapacitating  episodes  requiring  bed  rest
prescribed by a physician and treatment by  a  physician,  as  required  for
rating  under  intervertebral  disc  syndrome,  so  the  condition  is  most
appropriately rated using  the  General  Rating  Formula  for  Diseases  and
Injuries  of  the  Spine.   Because  of  the  multiple  spine   pathologies,
including DDD status post  discectomy  and  fusion,  as  well  as  SI  joint
involvement indicated by positive Patrick’s  and  Gaenslen’s  tests  and  CI
complaints of “hip” pain, the most appropriate  coding  is  analogous  to  a
combined 5243 (Intervertebral disc syndrome) to include fusion,  with  5236,
sacroiliac injury and weakness.   The  Board  considered  the  common  post-
surgical improvement of back ROMs, the CI’s pre-separation re-injury of  his
back and the sustained decreased ROM pre-separation.   The  two  exams  most
proximate to separation would rate 20% IAW the  General  Rating  Formula  by
ROM and include radicular pain.  After due deliberation, considering all  of
the evidence and  mindful  of  VASRD  §4.3  (reasonable  doubt),  the  Board
recommends a separation rating of 20%  for  the  left  SI  joint  and  spine
condition.

LBP  Condition  (Radiculopathy).   There  was  no  evidence   of   unfitting
peripheral nerve impairment in this case.  The CI  endorsed  hip  pain  (see
below) and episodic radiation  of  pain  into  his  legs  (particularly  the
left),  and  episodic  left  leg  numbness,  but  no  leg  weakness.   Board
precedent is that a functional impairment tied to  fitness  is  required  to
support a recommendation for  addition  of  a  peripheral  nerve  rating  at
separation.  The pain component of a radiculopathy  is  subsumed  under  the
CI’s primary unfitting lumbosacral condition as specified in §4.71a IAW  the
General Rating Formula for Diseases and Injuries  of  the  Spine,  “With  or
without symptoms such as pain (whether or not it  radiates),  stiffness,  or
aching in the  area  of  the  spine  affected  by  residuals  of  injury  or
disease.”   The  PEB   noted   the   condition   was   “without   neurologic
abnormality….”  An  electrodiagnostic  study  performed  three  months  pre-
separation (3  weeks  prior  to  the  NARSUM)  identified  left  L5  and  S1
radiculopathies, evidenced by  spontaneous  EMG  activity  in  several  left
sided muscle groups.  The NARSUM exam found no clinical evidence of  a  non-
pain radiculopathy.  The single  exam  which  reported  diminished  reflexes
(pain management note, two months pre-separation), was followed by the  pre-
separation VA C&P exam which documented normal reflexes.  The VA exam  noted
sensory deficit to light touch over the left  hip.   A  very  detailed  pain
management evaluation two months post-separation documented  abnormal  gait,
decreased (4/5) left leg knee flexion strength,  normal  reflexes,  and  CI-
reported paresthesias along the L5-S1 distribution  in  the  lower  leg  and
lateral foot.  None of the pre-separation exams  in  the  record  noted  any
motor deficits,  atrophy,  or  foot  drop.   The  pre-separation  report  of
abnormal gait (antalgic gait  at  pain  management  visit  two  months  pre-
separation) was most likely due to  pain,  as  the  motor  evaluations  were
normal.  The post-separation abnormal gait was matched with left  leg  motor
weakness.  The  motor  impairment  was  therefore  either  intermittent  [if
absent reflex is considered] or relatively minor and  cannot  be  linked  to
significant  physical  impairment.   Since   no   evidence   of   functional
impairment exists in this case, the Board cannot  support  a  recommendation
for additional rating based on peripheral nerve  impairment.   All  evidence
considered, there is not reasonable  doubt  in  the  CI’s  favor  supporting
addition of any lower extremity radiculopathy as an unfitting condition  for
separation rating.

Left Hip Pain Condition.  As previously elaborated,  the  Board  must  first
consider whether left hip pain  remains  separately  unfitting,  having  de-
coupled it from a combined PEB adjudication.  There was no evidence of  left
hip trauma or joint pathology.  The most likely cause of the CI’s  hip  pain
was SI joint dysfunction or radicular pain which was  considered  under  the
CI’s primary unfitting condition.  In  analyzing  the  intrinsic  impairment
for appropriately coding and rating the left hip pain condition,  the  Board
is left with a questionable basis for arguing that left hip pain was  indeed
independently unfitting.  The commander’s statement  and  permanent  profile
did not identify hip pain, and only  referenced  the  CI’s  back  condition.
The service treatment record did not reveal any  hip  injury  or  outpatient
visits related to hip pain.  There were no detailed hip  joint  evaluations,
with the only reference being the NARSUM’s “pain with internal  rotation  of
the left hip.”  This was noted in the  same  sentence  as  the  positive  SI
joint tests, and it is possible that SI joint pain was elicited by  internal
hip rotation.  There were no  hip  radiographs  or  other  evidence  of  hip
pathology in the record.  After due  deliberation,  the  Board  agreed  that
evidence does not support a conclusion that left hip pain,  as  an  isolated
condition, would have rendered the CI incapable of continued service  within
his MOS, and accordingly cannot recommend a separate service rating for it.

Remaining Conditions.  Other conditions identified  in  the  DES  file  were
hypertension  (VA  10%),  hypertriglyceridemia,  macrocytosis  (“no   anemia
noted”), cervical degenerative disc disease and degenerative joint  disease,
one episode of bronchitis, left knee pain  (associated  with  blunt  trauma,
none now),  ankle  pain  (unspecified  side),  headaches  (two  types),  and
sinusitis.  Several additional non-acute conditions  or  medical  complaints
were  also  documented.   None  of  these  conditions  were   occupationally
significant during the MEB period, none carried attached profiles  and  none
were  implicated  in  the  commander’s  statement.   These  conditions  were
reviewed by the  action  officer  and  considered  by  the  Board.   It  was
determined that none could be argued as unfitting and subject to  separation
rating.  No other conditions  were  service  connected  with  a  compensable
rating by the VA within 12 months of separation  or  contended  by  the  CI.
The Board therefore has no reasonable basis for recommending any  additional
unfitting conditions for separation rating.


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  combined  left  SI  joint  and  left  hip
condition was likely operant in this case and the condition was  adjudicated
independently of that regulation and policy by the Board.  In the matter  of
the left SI joint dysfunction  with  left  hip  pain  condition,  the  Board
unanimously recommends that it be adjudicated as two separate  condition  as
follows:  an unfitting left SI joint dysfunction, status-post  fusion  L4-S1
condition coded 5243-5236  and  rated  20%  IAW  VASRD  §4.71a;  and  a  not
unfitting left hip pain  condition.   In  the  matter  of  the  hypertension
condition or any other medical conditions eligible for Board  consideration;
the Board unanimously agrees that it cannot recommend any findings of  unfit
for additional rating at separation.


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  |
|Left SI Joint Dysfunction, S/P Fusion L4-S1,      |5243-5236   |20%     |
|including Radicular Pain                          |            |        |
|Left Hip Pain                                     |Not Unfitting         |
|COMBINED    |20%     |


____________________________________________________________________________
__

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20110619, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans' Affairs Treatment Record


            President
            Physical Disability Board of Review
SFMR-RB


MEMORANDUM FOR Commander, US Army Physical Disability Agency


SUBJECT:  Department of Defense Physical Disability Board of Review
Recommendation


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
                                       Deputy Assistant Secretary
                                           (Army Review Boards)