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AF | PDBR | CY2013 | PD-2013-02744
Original file (PD-2013-02744.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD-2013-02744
BRANCH OF SERVICE: Army  BOARD DATE: 20141029
SEPARATION DATE: 20070516


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Cavalry Scout) medically separated for low back and right hip pain. The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty, but he met alternate physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The low back and right hip conditions, characterized as “lumbago” and “right femoral neck stress fracture,” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “chronic low back pain (LBP) without neurologic deficit” and “chronic right hip pain status post stress fracture” as unfitting, rated 10% each, referencing the US Army Physical Disability Agency (USAPDA) pain policy for the hip with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) for the back. The CI made no appeals and was medically separated.


CI CONTENTION: “Fractures in hip and bad back. I still have a bad back and still unable to pick up my kids or stand on my feet for too long. I suffer from PTSD and I definitely should be rated at a higher percentage than just 30%.”


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 unfitting low back and right hip conditions are addressed below; no additional conditions, to include the contended posttraumatic stress disorder, are within the DoDI 6040.44 defined purview of the Board. 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 Board for Correction of Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20070410
 VA - (3 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain 5237 10% Chronic Low Back Strain 5237 10% 20070814
Chronic Right Hip Pain… 5099-5003 10% Residuals Stress Fracture Rt Hip 5253 20% 20070814
Other x 0 (Not in Scope)
 Other x 0
Combined: 20%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 200 70817 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Low Back Pain Condition. The first record in evidence for the LBP condition was an emergency room (ER) visit on 30 August 2006. The CI reported a 2-week history of LBP without antecedent trauma.
The examination was unremarkable other than back tenderness and he was treated with medications. A bone scan done a week previously for the right hip was normal. He began chiropractic treatment on 14 September 2006. Lumbar and thoracic spine X-rays that day were normal. A lumbar magnetic resonance imaging (MRI) a week later was also normal. At an evaluation on 12 November 2006 in primary care, he was noted to have a normal gait, but decreased thoracic curvature and muscle tightness in the lower back. He was treated with osteopathic manipulation on 18 November 2006 and noted to have bilateral lumbar muscle spasm. At a follow-up visit on 2 December 2006, the range-of-motion (ROM) was reduced with extension limited to 10 degrees and flexion to 60 degrees. Muscle spasm was present as well as two of five signs of non-organic pain (pain from maneuvers not expected to cause pain). Electrodiagnostic testing in January 2007 was normal per the MEB history (Form 2807, dated 7 February 2007). The narrative summary (NARSUM) was dated 16 January 2007, less than 4 months prior to separation. The CI reported the onset of pain during a training exercise in June 2006 without specific trauma. On examination, there was spasm of the lumbar spine and tenderness of the thoracic and lumbar spine. The neurological examination was normal as were the gait and posture. Heel and toe walking were normal. Atrophy was absent. The ROM was reduced from pain and stiffness. At the MEB examination on 7 February 2007, the CI reported difficulty sleeping due to his back pain and occasional tingling down his right leg. He stated that he had been in counseling for pain management. The examiner noted tenderness and that the ROM was limited in all planes by pain. The gait and neurological examination were normal. Paraspinal tenderness was present, but neither atrophy nor spasm recorded. At a physical therapy (PT) evaluation on 9 February 2007, he reported continued pain despite treatment. His gait was normal and atrophy absent. Spasm was not documented. The ROM was within functional limits with flexion to the mid-leg (estimate over 60 degrees), extension reduced by 25% (about 22 degrees), side bending normal and rotation 75% of normal (22 degrees). The ROM measurements in PT on 14 February 2007 were reduced with a forward flexion of 65 degrees (normal is 90) and a combined ROM of 185 degrees (normal is 240). The examiner noted that the r otation measurements were with a goniometer and the remainder of measurements used an inclinometer. The ROM was limited by pain; there were neither spasms nor abnormal gait present. The CI was evaluated in the primary care clinic in the VA system on 21 June 2007, a month after separation, to establish care. He was noted to be in no acute distress and to have symmetric motion and strength of his extremities. The neurological examination and gait were both normal. No comment was made on the ROM. At the VA Compensation and Pension (C&P) general examination performed on 14 August 2007, 3 months after separation, the CI reported LBP which flared weekly and lasted 3-7 days. He reported that during the flares “he couldn’t even play with his son.” He reported that he could stand 15-30 minutes and walk over ¼ mile but less than one mile. He denied incapacitation. On examination, he was in no acute distress with an erect posture and normal gait. Guarding and tenderness of the lower back was present, but without spasm documented. Lumbar spine X-rays were unremarkable. The ROM was not measured. A separate spine examination was scheduled, but the CI did not report for it.

The Board directed attention to its rating recommendation based on the above evidence. On the examinations proximate to separation, spasm is absent and gait and posture are normal. The ROM is reduced, but at a level which supports a 10% rating. Incapacitation is not documented. The imaging studies, including lumbar spine X-rays, a lumbar MRI and the second bone scan are all normal. The PEB and VA both rated the back at 10%, coding it 5237, lumbosacral strain. The Board found no route to a higher rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back pain condition.


Right Hip Condition. The CI presented to primary care on 1 June 2005, less than 4 weeks after accession, with a 5-day history of right hip pain after running. An X-ray that day was normal. The next day a bone scan revealed increased uptake consistent with a stress fracture. An MRI that day confirmed an early stress fracture of the femoral neck at the hip joint. The CI was evaluated in orthopedics on 7 June 2005 and it was determined, however, that this was a stress reaction (injury) rather than a fracture (actual break in the bone). He was placed on light duty and reassessed periodically. On 18 July 2005, his pain had resolved, he was able to jog and was eager to return to duty. On 26 July 2005, he was still doing well and released to resume training. The next record in evidence is a primary care evaluation for a headache, dated 3 October 2005, at which the CI also noted right hip pain. On examination, he was noted to have full ROM. He was treated with medications. The next record is an X-ray report of the left hip dated 17 August 2006. The CI reported a 1-week history of a dull ache in the left hip; the X-rays were normal. A bone scan performed on 22 August 2006 was normal without pathology in either hip. The NARSUM was less than 4 months prior to separation. The CI reported chronic right hip pain similar to the initial injury during basic training. On examination, neurological function was normal as were the gait and posture. Heel and toe walking were normal. Atrophy was absent. At the MEB examination on 7 February 2007, the CI reported swelling of his right hip from the stress fractures and a constant dull ache aggravated by activity. The examiner noted tenderness over the right hip. The ROM was not limited, but painful in all planes. The gait and neurological examination were normal. Paraspinal tenderness was present, but neither atrophy nor spasm recorded. At a PT evaluation on 9 February 2007, he reported continued back pain despite treatment. No complaint of hip pain was noted. His gait was normal and atrophy absent. At the VA primary care clinic appointment on 21 June 2007, the CI stated that the primary problem was with his back. He was noted to be in no acute distress and to have symmetric motion and strength of his extremities. The neurological examination and gait were both normal. At the VA C&P general examination on 14 August 2007, the CI reported chronic hip pain which was progressively worse since onset in basic training. He reported weekly flares which lasted 1-2 days. During the flares “he couldn’t do much at all.” He reported that he could stand 15-30 minutes and walk over ¼ mile but less than a mile. He denied incapacitation. On examination, he was in no acute distress with an erect posture and normal gait. Tenderness of the right hip was present, but without spasm documented. Hip and pelvis X-rays were unremarkable. The ROM was painful and is charted below. The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.


Right Hip (Thigh) ROM
(Degrees)
MEB ~ 3 Mo. Pre-Sep
VA C&P ~ 3 Mo. Post-Sep
Flexion (125 Normal) No limitation of movement 95 (72 on repetition, passive 98)
Extension (20) 10 (8 on repetition; passive 14)
External Rotation (45) 25 (18 on repetition; passive 31)
Abduction (0-45) 15 (09 on repetition; passive 18)
Adduction (45) 10 (10 on repetition; passive 08)
Comment Painful motion ROMs decline w/ repetition
§4.71a Rating 10 % 10 %

The Board directed attention to its rating recommendation based on the above evidence. The CI had a stress reaction of the right hip in basic training, but fully recovered with duty limitation and was able to return to duty and complete training. The records show that there was no evaluation for hip pain after 17 August 2006, 9 months prior to separation, other than for the MEB process. The CI was consistently noted to have a normal gait in the months prior to and following separation. After recovery from the initial injury, X-rays, an MRI and a bone scan were all normal.
The MEB examiner noted painful, but full motion. At the post-separation VA clinical evaluation, the hip motion was noted as symmetric. The VA C&P examination noted a significant reduction in the ROM in all planes. This is not consistent with the absence of pathology on imaging studies, a consistently normal gait and the ability to accomplish the alternative physical fitness test, absence of atrophy, or the normal ROM noted on the MEB examination. The probative value of this examination is accordingly reduced. The PEB coded the hip pain as analogous to degenerative arthritis, 5099-5003, and rated it at 10% IAW the USAPDA pain policy. The VA coded the hip as 5253, limitations in thigh motion, and rated it at 20% for abduction of less than 10 degrees. The Board determined that the examination upon which the VA rating was based was not consistent with the remainder of the evidence available for review. The Board then considered the other coding options available for the hip and found no route to a rating higher than the 10% rating adjudicated by the PEB. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right hip condition.


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 right hip was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the back and right hip conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131216, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








                 
XXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXX, AR20150008387 (PD201302744)


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 and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                       XXXXXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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