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)