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AF | PDBR | CY2013 | PD-2013-01222
Original file (PD-2013-01222.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-01222
BRANCH OF SERVICE: Army  BOARD DATE: 20150114
SEPARATION DATE: 20030331


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (92G10/Food Service Specialist) medically separated for low back pain (LBP). The back condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “low back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two conditions (right knee pain and sacroiliac joint dysfunction) for PEB adjudication. The Informal PEB adjudicated the LBP, sacroiliac pain and right knee pain as unfitting, rated 0%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: The CI elaborated no specific contention in her application.


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 ratings for the LBP, sacroiliac pain and right knee pain are addressed below. In this case, the LBP and the sacroiliac joint dysfunction are closely related conditions. In accordance with the VA Schedule for Rating Disabilities (VASRD) § 4.66 Sacroiliac joint which stipulates “The lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes,” the Board will consider the LBP and sacroiliac dysfunction together for fitness and rating determinations. No additional conditions are within the DoDI 6040.44 defined purview of the Board. Any condition or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may remain eligible for future consideration by the Board for Correction of Military Records.


 RATING COMPARISON :

IPEB – Dated 20030318
 VA* - based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Low Back Pain 5009-5003 0% Low Back Condition / Sacroiliac Joint Dysfunction 5295 NSC* STR
Sacroiliac Joint Dysfunction
Right Knee Pain Right Knee Condition 5257 NSC* STR
Other x 0 (Not In Scope)
 Other x 0 (equals SC, NSC & deferred)
RATING: 0%
 RATING: 0%
* Derived from VA Rating Decision (VA RD ) dated 200 30731 (most proximate to date of separation ( DOS ) ) . A VARD Appeal dated 20 041013 rated LBP at 10% and Right Knee Pain as 20% under Rt. Sciatica due to Rt. Sacroiliac Dysfunction.


ANALYSIS SUMMARY: The PEB combined the LBP, sacroiliac joint dysfunction, and right knee pain conditions as a single unfitting condition coded analogously to 5003 and rated 0% with application of the USAPDA pain policy AR 635-40 B24.f.
The 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 Board also noted that “bundling,” (the combining of two or more major joints) is permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings. The Board’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 Board 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 Disability Evaluation System 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.

Low Back Pain and Sacroiliac Joint Dysfunction. The CI experienced a fall during basic training on 16 October 2002 causing neck and upper back pain. X-rays (of cervical, thoracic and lumbar spine) were negative for evidence of fracture or dislocation. The CI was treated with rest, pain medications, and physical therapy. By the time of a physical therapy examination on 9 December 2003, mid-back pain was improved with no pain at rest and 1/10 pain with activity aggravated by heavy lifting. On examination there was mild tenderness to palpation of the trapezius muscle at the shoulder blade. By the time of the MEB orthopedic narrative summary (NARSUM) on 24 February 2003, the back pain was described as low back pain. The pain was aggravated after prolonged standing, prolonged walking, and strenuous activity. The CI denied radiation of pain and denied paresthesia of the lower extremities (numbness and tingling). The pain was mild (1/10) with office work and the CI noted she did well if she avoided military activities and training. On examination, sensation and reflexes were normal. Provocative maneuvers signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative. There was sacroiliac and hip pain with a provocative maneuver that stresses the sacroiliac and hip joints (FABER test). The CI reported bilateral hip pain since the second week of basic training; however the examiner noted that X-rays and bone scan of both hips were normal and the hip examination was otherwise normal (full range-of-motion [ROM]). The orthopedic surgeon recorded having observed the CI on multiple occasions in the hospital with a normal gait. The orthopedic surgeon noted that X-rays of the lumbosacral spine and the sacroiliac joints were normal. The orthopedic surgeon diagnosed LBP and sacroiliac joint dysfunction. At the MEB physical examination on 26 February 2003, the CI reported LBP. On examination, recorded on form DD Form 2808, the spine examination was indicated as normal, however there was tenderness of the soft tissues near the right sacroiliac joint. There was no VA Compensation and Pension (C&P) examination proximate to separation (the first after separation examination was 8 September 2004, 17 months after separation). The Board first considered whether the LBP and sacroiliac dysfunction was unfitting when considered separately from the knee pain condition. All Board members agreed the evidence of the treatment record indicated that back pain and sacroiliac dysfunction significantly interfered with return to military training and was therefore unfitting.

The Board directs its attention to its rating recommendation based on the above evidence. The PEB rated the LBP and sacroiliac dysfunction 0% with application of the USAPDA pain policy and noted the rating also included the right knee. As noted previously, the Board’s rating recommendation is for the LBP and sacroiliac dysfunction together in accordance with VASRD §4.66 Sacroiliac joint which stipulates “The lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes.” In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation. The Board notes that the 2002 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.
The Board must correlate the above clinical data with the 2002 rating schedule (applicable diagnostic codes include: 5292 limitation of lumbar spine motion; 5293 intervertebral disc syndrome (based on incapacitating episodes); and 5295 (Lumbosacral strain). Examinations proximate to separation did not show limitation of motion. There was no evidence of intervertebral disc syndrome, and after the initial injury in October 2003, there were no incapacitating episodes requiring bed rest prescribed by a physician. All members agreed a 10% rating was supported based on characteristic pain on motion under VASRD diagnostic code 5295 (lumbosacral strain). There was insufficient evidence to support higher ratings under this code such as muscle spasm on forward bending. At the time of the MEB NARSUM, there was no radiating pain or objective findings to support consideration of a separately unfitting peripheral nerve disability rating. 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 with sacroiliac dysfunction condition (coded 5299-5295).

Right Knee Pain. The first STR entry for right knee pain was 22 September 2002 (third week of basic training) when the CI sought care for an abrasion on the right knee after a fall (and left wrist pain). On examination, the right knee was not swollen or tender and demonstrated full ROM. X-rays were indicated as normal. On follow-up in clinic the next day on 23 September 2002, no mention of knee pain was made (only left wrist sprain). At the time of the MEB orthopedic NARSUM on 24 February 2003, the CI reported right knee pain since the second week of basic training with occasional popping with pain. There were no symptoms of swelling or instability. The CI denied any specific injury or trauma. The orthopedic surgeon noted the CI reported a remote history of possible locking but none recently. Examination of the knee was normal including ROM and negative tests for instability, meniscus problems, or patellofemoral pain problems. The examiner noted that X-rays of the right knee were normal. The orthopedic surgeon concluded the right knee was moderately to severely symptomatic but also recorded having observed the CI on multiple occasions in the hospital with a normal gait. At the MEB physical examination on 6 February 2003, the CI reported that her knee locks. On examination, recorded on form DD Form 2808, the extremity examination only noted the sacroiliac joint pain on the right and no abnormality of the knee was recorded. There was no VA C&P examination proximate to separation (the first after separation examination was 8 September 2004, 17 months after separation). The Board first considered whether the right knee pain was unfitting when considered separately from the LBP and sacroiliac dysfunction. Except for the 22 September 2002 knee abrasion, the Board noted there were no STR entries for right knee pain until the MEB NARSUM on 24 February 2003. The physical profile completed by the NARSUM orthopedic surgeon dated 24 February 2003 listed the knee along with the back. Although the MEB NARSUM suggested severe knee pain, the Board noted the absence of medical documentation for duty limiting knee pain or profiles prior to the MEB NARSUM. The Board also noted the normal examinations and X-rays. Therefore, all Board members concluded that the evidence did not reasonably justify a finding of separately unfit for the right knee pain. The Board concluded therefore that the right knee pain condition could not be recommended for separately unfitting disability 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 LBP, sacroiliac dysfunction and right knee pain was operant in this case and the conditions were adjudicated independently of that policy by the Board. In the matter of the LBP and sacroiliac dysfunction condition, the Board unanimously recommends an unfit determination with a disability rating of 10%, coded 5299-5295 IAW VASRD §4.71a.
In the matter of the right knee condition the Board unanimously recommends a separately not unfit determination and therefore no separate disability rating. 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
Low Back Pain and Sacroiliac Joint Dysfunction 5299-5295 10%
Right Knee Pain Not Unfit
COMBINED 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130804, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record





                                   
XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXX, AR20150009543 (PD201301222)


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              XXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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