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AF | PDBR | CY2014 | PD-2014-01154
Original file (PD-2014-01154.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-01154
BRANCH OF SERVICE: Army  BOARD DATE: 20150113
SEPARATION DATE: 20090831


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty 0-2 (Military Police) medically separated for lumbar spine and pelvis conditions. The conditions 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 lumbar spine and pelvis conditions, characterized as lower back pain” and osteitis pubis,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded eight other conditions “chronic left ankle pain,” “bilateral osteoarthritis of the knees,” hemorrhoids,” “recurrent herpes simplex virus,” “hypertension,” “exercise-induced urticarial,” “pes cavus with left plantar fasciitis,” and “dyshidrotic eczema,” as medically acceptable, for PEB adjudication. The Informal PEB adjudicated chronic low back pain” and “bilateral anterior pelvic pain,” as unfitting, rated 10% and 10%, citing criteria of the VA Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting . 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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.










RATING COMPARISON :

Service IPEB – Dated 20090528
VA - (2 Mos. Post-Separation)
Condition
Code Rating Condition Code Rating Exam
Chronic Low Back Pain 5299-5243 10% Lumbar Spondylosis with Mild Facet Degenerative Joint Disease 5243 10% 20091029
Bilateral Anterior Pelvic Pain 5299-5236 10% Osteitis Pubis 5236 10% 20091029
Other x 8 (Not in Scope)
Other x 14
Combined: 20%
Combined: 70%
Derived from VA Rating Decision (VA RD ) dated 200 91118 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Low Back Condition. The narrative summary (NARSUM) noted the CI reported low back pain (LBP) that developed during pregnancy in 2007. The LBP was localized and radiated to the hips, but was not associated with any lower extremity (LE) numbness or tingling, or other neurological symptoms. Magnetic resonance imaging (MRI) of the lumbar spine on 22 October 2008 showed mild degenerative disc disease without evidence of spinal stenosis or nerve encroachment. A pain management evaluation on 18 December 2008, 4 months prior to separation, noted painful lumbar range-of-motion (ROM), with normal LE strength, sensation, and reflexes, and normal hip rotation. The examiner’s assessment was that the radiating pain to the hips was from the lumbar spine. An epidural steroid injection was recommended. According to the NARSUM the CI declined steroid injections and despite medication, physical therapy (PT), and chiropractic treatments the CI continued to report LBP. A note in the service treatment record (STR) indicated that 10 March 2009 the CI was on quarters for 2 days due to LBP.

At the MEB examination on 1 April 2009, 5 months prior to separation, the CI reported LBP without LE symptoms or bowel/ bladder problems. The MEB physical exam noted a normal gait and stance. The MEB examiner cited the remainder of the exam from the DD Form 2808, Report of Medical Examination, on 4 March 2009, 6 months prior to separation. The thoracolumbar (TL) spine was normal in appearance without muscle spasm, with tenderness to palpation (TTP) over the lower lumbar spine, without TTP of the sacroiliac (SI) joints. Strength, sensation, and reflexes of the LE were normal. PT measured TL ROM after three repetitions was flexion of 90 degrees (normal 90 degrees), with combined ROM of 220 degrees (normal 240 degrees).

At the VA Compensation and Pension (C&P) exam
ination on 29 October 2009, performed 2 months after separation, the CI reported constant LBP, rated two out of ten, with flare-ups every 3 to 4 months, lasting 2 days. The CI reported a 2-day period of physician prescribed bed rest in the last 12 months. On the VA examination there was normal gait and posture. There was no tenderness, muscle spasm, guarding, or painful motion. Strength, sensation, and reflexes of the LE were within normal. Testing for radiculopathy (Lasegue’s) was negative. TL ROM was flexion of 75 degrees, with combined ROM of 185 degrees, and no additional limitation of ROM with repetition. Lumbar and thoracic spine X-rays on 30 October 2009 showed mild degenerative changes and MRI on 13 November 2008 was unchanged from the previous study.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 10%, coded 5299-5243 (analogous to intervertebral disc syndrome) and the VA also rated it 10%, coded 5243. The Board agreed that the evidence in the record supported the 10% rating IAW the VASRD General Formula for Rating the Spine based upon limited ROM, but did not support the 20% rating specified as TL flexion of greater than 30 degrees but not greater than 60 degrees, or combined ROM not greater than 120 degrees, or guarding or muscle spasm sufficient to cause an abnormal gait or spinal contour. The Board reviewed to see if a higher evaluation was achieved rating based upon incapacitating episodes, but only one episode of physician prescribed bed rest of 2 days duration was documented in the 12 months prior to separation, which does not meet the threshold requirement for a compensable rating according to VASRD specified as duration of incapacitating episodes of “at least one week in the past 12 months. There was also no evidence of peripheral nerve impairment related to the back condition for additional disability rating. The pain consultant noted radiating lumbar pain, but pain, whether or not it radiates, is subsumed in the §4.71a rating according to the VASRD (spine rating) rules in effect at the time of separation.to the current VASRD General Formula for Rating the Spine. 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 low back condition.

Pelvis Condition. The NARSUM noted the CI developed pelvic pain during pregnancy at the same time as the LBP. The CI was referred to PT for separation of the pubic symphysis (joint between the left and right sides of the anterior pelvic bone- pubic bone). A PT note on 7 December 2007 indicated she was ambulating without crutches, reported pain occasionally, and there was no TTP of the pelvis. Approximately 3 months later the CI was evaluated for reported chronic pelvic pain since giving birth and the examination noted TTP of the pubic symphysis, with an otherwise normal musculoskeletal examination. Computed tomography (CT) scan of the pelvis 17 March 2008 noted no pertinent abnormality. MRI of the pelvis on 24 April 2008 noted nonspecific increased signal in the left side of the symphysis pubis. A bone scan in August 2008 noted no abnormality in the pelvis, but there was increased uptake in the right femur, which was not in the area of reported pain and was noted as a mild stress reaction. A primary care visit on 22 October 2008 noted that the pain had initially begun in the pubic symphysis and lower back, eventually with radiation toward the hips. On examination neither hip was TTP and there was full painless ROM without instability, but there was TTP the pubic symphysis. A pain specialist evaluation on 18 December 2008 noted LBP that radiated to both hips. Examination noted normal lumbar spine ROM with pain and normal bilateral hip ROM. An orthopedic evaluation on 27 March 2009, 5 months prior to separation, noted a 16-month history of pelvic pain following pregnancy. On examination there was TTP of the pubic symphysis but the pelvis was stable. There was no TTP of the hips and hip ROM was full, without painful motion. Strength and sensation of the LE were normal. The orthopedic diagnosis was osteitis pubis (inflammation of the pubic symphysis) and the CI was offered steroid injection, but chose to continue with conservative treatment. According to the NARSUM the pelvic pain had decreased significantly postpartum, but had not completely resolved. At the MEB examination on 1 April 2009, 5 months prior to separation, the CI reported pain in the lower back and pelvis rated two out of ten. The MEB examination noted a normal posture and gait. The MEB examiner cited the remainder of the exam from the DD Form 2808, which noted mild TTP over the pubic symphysis. Except as noted in the back section, the examination was otherwise normal.

At the VA C&P exam
ination on 29 October 2009 performed 2 months after separation, the CI reported pain in both hips after having a baby in November 2007, with use of crutches for a period of time. The CI reported a history of back pain that radiated around the pelvis with current intermittent symptoms with remissions, treated with activity limitations with a fair response. Examination of the bilateral hips noted painful limited ROM of both hips with bilateral flexion of 80 degrees (normal 125 degrees), extension of 8 degrees (normal 20 degrees) left abduction of 40 degrees (normal 45 degrees); right abduction of 30 degrees; with full adduction and rotation. Bilateral hip X-rays showed no evidence of degenerative joint disease or stress fracture. The VA examiner diagnosed bilateral hip strain, but commented that the hip pain was most likely referred pain from the low back condition.
The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the pelvis condition 10%, coded 5299-5236 (analogous to SI injury) and the VA rated it 10%, coded 5236. The VA also rated the right and left hips 10% each for hip strain, coded 5099-5024 (analogous to tenosynovitis). The evidence in record supports that during pregnancy the CI experienced musculoskeletal pain of the pelvis, a very common occurrence due to the hormonal effects of pregnancy on the pelvic ligaments, which improved significantly in the postpartum period. At the post-separation VA examination the CI reported intermittent episodes of bilateral hip pain related to the pelvis condition and notes in the STR indicated that both the pelvis and back pain radiated to the hips; the pain specialist and the VA examiner both indicated that the hip pain was most likely related to the CI’s LBP condition. The Board opined that the CI’s radiating pain may have been related at times either to the CI’s back or pelvis condition, or both. However, the Board noted that there was no evidence in the STR of an unfitting hip condition and neither the MEB nor the PEB addressed any hip condition. The Board agreed that the disability due to the pelvis condition met a 10% rating coded analogously to SI injury IAW VASRD General Formula for Rating the Spine based on pain, but did not meet a 20% evaluation which would require evidence of an abnormal gait. There was no evidence of incapacitating episodes or any other ratable impairment of the pelvis to provide for additional or 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 pelvis 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. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matters of the low back condition and the pelvis conditions, both 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 20140224, w/atchs
Exhib
it 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, AR20150009566 (PD201401154)


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

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