RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-00221	
BRANCH OF SERVICE:  Army	BOARD DATE:  20150812
SEPARATION DATE:  20030716		

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Patriot Fire Control Enhanced Operator Maintainer) medically separated for bilateral femoral and hip pain.  The condition could not be adequately rehabilitated 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).  The condition characterized as “bilateral femur stress fracture” and “left greater trochanteric bursitis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The informal PEB adjudicated “bilateral femoral and hip pain due to stress fracture of the femurs without loss of joint motion” as unfitting, rated 0%.  The PEB did not rate bursitis separately due to the pyramiding rule.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI contended that her condition has worsened since discharge.  Her full submission is at Exhibit A.

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 (VA), 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 20070301	VA – (Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Stress Fractures of the Femurs …	5022	0%	Bilateral Stress Fracture of the Femurs	5299-5251	NSC	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)		Other x 0 (Not in Scope)	
Combined:  0%	Combined:  NSC	
Derived from VA Rating Decision (VARD) dated 20070403 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  As noted above, the PEB combined the bilateral hip conditions under a single disability rating, coded 5022.  Although VASRD §4.71a permits combined ratings of two or more joints under 5022 (5003), it allows separate ratings for separately compensable joints.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication 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.  To that end, the evidence for the bilateral hip conditions are presented; with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Bilateral Femoral Stress Fractures.  Bilateral hip pain developed during Advanced Individual Training in August 2002 (11 months prior to separation).  The pain was “worse with running,” however, there was no documentation of trauma.  A nuclear medicine bone scan in September 2002 was “mildly abnormal” and consistent with bilateral femur stress fractures.  The CI was treated with activity restrictions (temporary and permanent profiles), physical therapy, medications, and hip injections.  Radiographs and a second bone scan performed in January 2003 (6 months prior to separation) were normal, without evidence of fracture, dislocation, or bony abnormalities.  On the MEB DD Form 2697-1 Report of Medical Assessment (dated 30 January 2003; 6 months prior to separation), the CI reported taking medications for pain and being “on crutches since 18 November 2002 and unable to go to school.”  The MEB DD Form 2808, Report of Medical Examination, dated 31 January 2003, did not document a hip examination, but annotated “bilateral stress fractures of the lower extremities.”  The MEB narrative summary (NARSUM) was dated 17 April 2003 (3 months prior to separation).  The CI reported pain and discomfort when walking and climbing stairs.  The examiner documented a left sided antalgic gait; bilateral tenderness on palpation of the proximal femurs, left greater than right; bilateral pain (left greater than right) with flexion and internal hip rotation; left hip pain with external rotation; and active full range-of-motion (ROM) of the hips.  

The CI did not appear for the scheduled VA C&P exam.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the bilateral hip condition without loss of motion as unfitting, rated 0% and coded 5022 (periostitis).  The VA granted no service connection after failure to appear citing no STR documentation of chronicity and no post-separation examination on which to base any disability rating.  

The Board first considered if the individual hip conditions, having been de-coupled from the combined PEB adjudication, were reasonably justified as separately unfitting as established above.  In this case, both hips were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  There are no unilateral distinctions with regards to clinical features or fitness considerations.  It is speculative to conclude that the disability confined to a single hip would have rendered the CI incapable of performing her MOS; and, it is reasonable to surmise that it was the combined effect of both hips which rendered her unfit.  Furthermore, the bilateral diagnosis supported a single 5003 based rating for “2 or more major joints.”  Members agreed, therefore, that there were insufficient grounds for recommending separate right and left hip disability ratings in this case.

The Board then considered the rating recommendation.  The VASRD §4.71a permits combined ratings of two or more joints under 5022 (5003) if degenerative arthritis is established by radiographic findings and limitation of motion.  There was documentation of painful motion of the bilateral hips.  However, there was no evidence for compensable ratings under any of the codes for limitation of motion at the hip, such as ankylosis, thigh flexion (5252); extension (5251); or abduction, adduction or rotation (5253).  There was no documentation of nonunion or malunion (5255) of a femoral neck or shaft fracture for rating under the femur codes.  Application of VASRD §4.40 (functional loss) and §4.59 (painful motion) was also considered, however, there was no documentation of muscle spasm, crepitation on motion, an unstable or malaligned joint, or other periarticular pathology.  The Board also discussed whether there was STR evidence of a chronic disability.  Prior to separation bilateral hip imaging documented resolution of the bilateral stress fractures and radiographs confirmed the absence of fracture, bony deformity or arthritis prior to separation.  There was no post-separation evidence that documented a chronic disability.  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 bilateral hip condition.  

Left Hip Bursitis.  The left hip bursitis was profiled, implicated in the NARSUM and identified and forwarded by the MEB.  The PEB bundled the condition together with the bilateral stress fractures and adjudicated them as unfitting, however further cited that the “bursitis could not separately be rated due to pyramiding.”  The left hip bursitis could be reasonably justified as separately unfitting.  However, the Board considered if a separate rating for the condition was defensible in this case, and members agreed that a separately ratable impairment could not be discerned without violation of VASRD §4.14 (avoidance of pyramiding).  The Board concluded therefore that this condition could not be recommended for additional 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.  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 bilateral hip stress fractures condition 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 20130402, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXX, AR20150018442 (PD201300221)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA