RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	CASE:  PD1300212
BRANCH OF SERVICE:  Army	BOARD DATE:  20130820
Date of SEPARATION:  20040308

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (11B/Infantry) medically separated for a left hip condition.  The injury occurred in 2002 when the CI was struck from behind by a five ton truck and was crushed against the tailgate of another truck.  He received surgery and physical therapy (PT), but could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Chronic left hip pain from acetabular fracture was forwarded to the Informal Physical Evaluation Board (IPEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The IPEB adjudicated left hip pain condition as unfitting, rated 20%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB, but an IPEB reconsideration was conducted, which affirmed the IPEB finding and rating.

CI CONTENTION:  “Because the prior DoD disability rating was not fair.”

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 rating for the unfitting left hip pain is addressed below.  Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

The Board acknowledges the CI’s assertion that the prior DOD was unfair and suggests a higher rating should have been granted on the unfitting medical condition documented at the time of separation.  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

RATING COMPARISON:

Service IPEB Reconsideration – Dated 20030912	VA* - (~5.4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Hip Pain...	5253	20%	Residuals Left Acetabular Fx...	5253	10%**	20040818	
			Residual Scar, S/P ORIF Left Acetabular Fx	7804	10%	20040818	
No Additional MEB/PEB Entries	Other x 5	20040818	
Combined:  20%	Combined:  30%	
* Derived from VA Rating Decision (VARD) dated 20041015 (most proximate to date of separation (DOS))** Rating adjusted to 30% in VARD dated 20060213 based on C&P 20040818 and Decision Review Officer De Novo review effective 20040309 or day after DOS

ANALYSIS SUMMARY:

Left Hip Pain Condition.  The narrative summary (NARSUM) dated 15 July 2003 noted the CI was injured when a five ton vehicle backed into him at low speed and pinned him against another vehicle.  His injuries included a closed fracture of the left acetabulum and a soft tissue shear injury that was evacuated and treated with antibiotics, but did not involve muscle loss.  He underwent open reduction and internal fixation for the fracture.  The CI initially did well post-operatively, but his hip worsened over time.  A CT scan of the pelvis was performed which showed a comminuted fracture in good anatomical position, felt to be healing.  Despite treatment the CI continued with pain and required a cane for ambulation.  At the MEB NARSUM examination 15 July 2003, approximately 8 months prior to separation, the CI reported worsening hip pain.  The MEB exam noted left hip range-of-motion (ROM) of abduction of 10 degrees (normal 45); internal rotation of 0 (normal 40); external rotation of 20 (normal 60); and flexion of 85 (normal 125).  There was tenderness to palpation (TTP) of the left groin and decreased sensation in the distribution of the lateral femoral cutaneous nerve, otherwise motor and sensation were intact.  It was noted that the CI was unable to weight bear without a cane and that he had a severe antalgic gait.  Left hip X-ray dated 17 July 2003 showed surgical hardware in place, a healed acetabula fracture, and moderate left hip osteoarthritis.  A MEB NARSUM addendum dated 4 November 2003, approximately 4 months prior to separation, clarified the etiology of the CI’s hip dysfunction as moderate post-traumatic left hip arthritis with left hip pain and loss of motion, requiring the use of a cane for ambulation, and traumatic left femoral cutaneous nerve palsy.  There was no mention of fracture malunion or poor healing.  A second MEB NARSUM addendum dated 21 January 2004, approximately 6 weeks prior to separation by the same physician, noted left hip ROM was flexion 30 degrees; internal rotation 10; external rotation 10; abduction 10; adduction 10 degrees and a clear hip ‘malunion’.  The examiner noted a cane was needed for ambulation secondary to pain.  At the VA Compensation and Pension (C&P) joints examination on 18 August 2004, approximately 5 months after separation, the CI reported left hip pain aggravated by standing and sitting.  He reported numbness and paresthesias of the left anterior thigh.  The CI reported flare-ups in bad weather, but no incapacitating episodes in the past year.  The VA examiner noted the CI used a cane, had a marked limp on the left, and had significant difficulty getting on and off the examining table.  On examination there was a well healed 13 centimeter scar in the left inguinal area without instability or irritation.  There was ‘exquisite’ TTP of the inguinal area, lateral hip and buttock areas.  Left hip ROM was flexion of 50 degrees (normal 125); extension of 10 (normal 30); external rotation of 0 (normal 60); internal rotation of 0 (normal 40).  Motor function of the left hip was noted to be “at most, 1/5 with severe hip pain.”  Quadriceps and hamstring muscles strength was 5/5.  The examiner noted that the CI’s hip strength and ROM were decreased due to pain and it was not possible to determine DeLuca requirements because of pain with any attempts at repetitive motion testing.  Left hip X-ray showed union of the acetabular fracture and the presence of well positioned surgical screws.  The C&P general exam, approximately a week later, the examiner noted no complaints of numbness in the groin.  There was ‘some’ TTP in the left inguinal area, normal sensation and strength and neurologic exam, and a well healed scar.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the left hip condition post-acetabula fracture at 20% coded as 5253 based on limited abduction.  No higher rating is achievable under this code.  The initial 15 October 2004 VARD rated the condition at 10%, also coded as 5253, based on limited adduction.  The CI filed a Notice of Disagreement and a Decision Review Officer Decision (DROD) on 13 February 2006 noted the hip disability should have been coded analogously to femur impairment with marked hip disability and determined a revised disability rating of 30%.  The Board deliberated the rating of the CI’s left hip condition.  The Board agreed that the CI’s left hip decreased ROM, with abduction of 10 degrees, noted at the MEB exam, met the 20% rating of 5253.  There was no higher rating achievable based on limited ROM.  The Board considered if an additional rating was indicated for muscle injury IAW §4.56.  There was no evidence in the record of muscle impairment due to trauma or surgery.  The MEB exam noted normal left lower extremity motor examination.  The C&P joints exam noted a hip strength of 1/5 due to pain; the C&P general examination a week later noted no muscle atrophy and a normal motor examination.  The various examination findings suggest that the CI’s abnormal gait was due to pain from the hip, rather than muscle weakness or motor nerve injury.  The Board concluded that additional rating of the left hip condition for muscle disability was not supported by the record.  The Board next considered if an additional disability rating was justified for peripheral nerve impairment IAW §4.124a.  The MEB exam noted TTP of the left groin and decreased sensation in the distribution of the lateral femoral cutaneous nerve.  The first MEB addendum listed traumatic left femoral cutaneous nerve palsy as a diagnosis contributing to the left hip dysfunction.  At the C&P joint exam the CI reported left anterior thigh numbness and paresthesias.  On exam there was tenderness of the anterior, lateral and posterior left thigh and the examiner noted the CI’s paresthesias to have hyper-esthetic and “pins and needles” components.  The Board opined that the CI’s lateral cutaneous nerve neuropathy was at most moderate and could be rated no higher than 0% code 8529 of no benefit to the CI.  The Board noted the DROD rated the hip condition 5255 (femur malunion with marked hip disability) at 30% stating:  “this (CI’s) disability is not specifically listed in the rating schedule; therefore, it is rated analogous to a disability (malunion) in which functions and symptoms are closely related.”   The Board then deliberated whether the use of an analogous code for malunion of the hip was indicated.  The Board noted an orthopedic surgeon report found in the MEB NARSUM addendum on 21 January 2004 showed a “clear hip malunion” referring to a CT scan of March 2003, but notes this same surgeon initially determined no malunion from this same scan.  The Board further noted the reports from this surgeon indicating no hip malunion on an X-ray performed on 17 July 2003 and in the MEB NARSUM addendum performed in 4 November 2003.  The Board further noted the VA’s X-ray of 18 August 2004, which showed a good union of the fracture sites or no malunion.  Lastly, the Board noted the C&P general exam, also in August 2003, noted no complaints of numbness in the groin.  There was “some” TTP in the left inguinal area, normal sensation and strength and neurologic exam.  The Board unanimously agreed that the preponderance of evidence in the record did not support either the presence of hip malunion at the time of or after separation and or the application of code 5255.  The Board was unable to find any additional appropriate VASRD coding for rating consideration.  The Board therefore agreed that the CI’s left hip condition was best coded as 5253 and rated at 20%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends that there be no recharacterization of the CI’s disability determination.

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 matter of the left hip pain condition, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at separation.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION	VASRD CODE	RATING	
Left Hip Pain	5253	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130429, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB / XXXXXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXXX, AR20130021809 (PD201300212)

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