RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00165
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20070502

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Army E-3 (Healthcare Specialist) medically separated for ankle and hip condition.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “right ankle pain and instability, secondary to ATFL and CFL tears” and “bilateral hip pain secondary to greater trochanteric bursitis”, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The informal PEB adjudicated “chronic pain, right ankle,” citing application of the US Army Physical Disability Agency (USAPDA) pain policy, and “bilateral trochanteric bursitis,” with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD), as unfitting, rated 10% and 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals, and was medically separated. 

CI CONTENTION:  Her condition continues to worsen and negatively impact her daily activities.  Her complete 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 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 20070416	VA* - (3 Mo. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Ankle	5099-5003	10%	Ligamentous Tear and Strain, Right Ankle	5271	0%	20070810	
Bilateral Trochanteric Bursitis	5019	0%	Trochanteric Bursitis, Right Hip	5253-5019	10%		
			Trochanteric Bursitis, Left Hip	5253-5019	10%		
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2 (Not in Scope)	
Combined/Rating:  10%	Combined:  20%	
*Derived from VA Rating Decision (VARD) dated 20080228 (most proximate to date of separation [DOS]).   
ANALYSIS SUMMARY:  The PEB combined the left and right hip conditions under a single disability rating as bursitis (coded 5019).  Diseases under diagnostic code 5019 are rated on limitation of motion of affected parts as degenerative arthritis (coded 5003).  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for Service rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Right Ankle Condition.  The service treatment record (STR) documents that the CI sustained a right lateral ankle strain while on a road march.  Initial radiographs showed no fracture.  A right ankle MRI showed a bone contusion, ligament tears, and a possible partial tendon tear.  A right ankle X-ray was unremarkable.  A bone scan showed stress changes in the right foot and ankle.  An orthopedic surgery right ankle exam documented range-of-motion (ROM) values of dorsiflexion of 20 (20 normal) and plantar flexion of 45 (45) degrees.  A follow-up orthopedic surgery encounter documented improvement of right ankle instability with 6 months of physical therapy (PT), and concomitant development of her greater trochanteric bursitis (inflammation of the bursa [fluid-filled sac near joint] at lateral hip).  The right ankle ROM values were dorsiflexion of 20 (20) and plantar flexion of 45 (45) degrees.  The narrative summary (NARSUM) recounted the history and interventions.  The CI reported that ankle instability had improved since her initial injury.  Her chief complaint was chronic pain and therefore she declined to have surgical intervention.  The right ankle exam revealed tenderness with no palpable stepoff.  There was no subtalar pain and very minimal discomfort with tibial tilt (assesses lateral ankle ligaments).  The ankle drawer test (assesses anterior talofibular ligament) was negative.  The pain limited ROM values, measured with a goniometer, were dorsiflexion of 10 (0,4,8) (20) and plantar flexion of 45 (45,45,45) (45) degrees.  Bilateral tibia and fibula X-rays, including knee and ankle joints, were unremarkable.  The compensation and pension (C&P) exam recorded intermittent, progressive, lateral, right ankle pain.  Pain was associated with swelling one to two times a week.  Symptoms were exacerbated by activity and walking and relieved by the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen and ice.  The physical exam documented a normal posture and gait without ambulatory aids.  The right ankle exam revealed mild tenderness at the lateral malleolus (ankle rounded bony prominence) with no swelling or heat.  Rotation caused no pain and the anterior drawer test was negative.  The ROM values were dorsiflexion of 20 (20) and plantar flexion of 45 (45) degrees.  On three repetitions of flexion and extension there was no decreased excursion secondary to pain, fatigue, muscle weakness, or lack of endurance.  Strength, sensation, pulses, and deep tendon reflexes (DTRs) were normal.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle 10% (coded 5099-5003).  The PEB cited slight chronic pain and not requiring daily narcotic therapy.  The VA, citing the C&P exam 3 months after separation, rated the right ankle 0% (coded 5271).  The VA cited normal ROM without pain or instability.  The ROM values documented in the proximate exams (orthopedic surgery X 2, MEB, C&P) were essentially normal and did not support a minimal rating under 5270 (ankle, ankylosis of) or 5271 (ankle, limited motion of).  The decreased dorsiflexion (0/4/8) in the MEB exam is inconsistent with the 3 other proximate exams and is therefore assigned less probative value.  There was no deformity for consideration under 5270 (ankle, ankylosis), 5272 (subastragalar or tarsal joint, ankylosis of), or 5273 (os calcis or astragalus, malunion of).  There was no excision of the astragalus for consideration under 5274 (astragalectomy).  Board members agreed that there was sufficient evidence of pain with use prior to separation, as well objective exam and imaging findings, to support a 10% rating considering VASRD §4.40 (functional loss) and §4.59 (painful motion).  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 ankle condition.

Bilateral Hip Condition.  The STR documents that during the conservative management of her ankle strain, the CI developed bilateral hip pain.  A bone scan showed increased activity along the left lateral femur suggesting a thigh splint (pain/inflammation at insertion of thigh adductor muscles).  In an attempt to relieve pain and inflammation, the CI underwent bilateral intra-bursal (trochanteric bursa) injections of local anesthetic and corticosteroid.  Bilateral hip imaging studies (X-ray and MRI) were unremarkable.  The NARSUM documented that while being treated in a short leg weight bearing cast, the CI developed bilateral hip pain.  Bursa steroid injections and PT did not relieve symptoms.  Symptoms were controlled with daily use of an NSAID (Indomethacin), opioid/analgesic combination (Vicodin), and tricyclic antidepressant (Elavil).  The hip exam revealed exquisite point tenderness over the greater trochanteric bursae.  There was no complaint of pain with loading and stressing.  Strength and sensation were grossly intact.  The hip active ROM values, limited by pain, are listed in the chart.  The C&P exam reported “Presently feels hip pain is progressive in nature with any pressure on the outside of the hip as bumping into a chair. … She is unable to sleep on her side secondary to pain.”  The physical exam documented “There is marked tenderness bilaterally at the trochanteric bursa. … On three repetitions of flexion and extension, there is no decreased excursion secondary to weakness, pain, fatigue or lack of endurance.”  The hip active ROM values are listed in the chart.  Strength, sensation, and DTRs were normal.

The ROM evaluations which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

           DOS 20070502
Hip (Thigh) ROM
(Degrees)	PT ~2 Mo. Pre-Sep	MEB ~ 2 Mo. Pre-Sep	VA C&P ~ 3 Mo. Post-Sep	
Bilateral	Left	Right	Left	Right	Left	Right	
Flexion (125 Normal)	WFL *	WFL	105 (95,105,105)	105 (95,100,105	0-125	0-125	
Extension (20)	#	#	10 (10,10,10)	10 (10,10,10)	#	#	
External Rotation (45)	#	#	#	#	#	#	
Abduction (0-45)	#	#	45 (45,45,45)	45 (45,45,45)	0-45	0-45	
Adduction (45)	#	#	#	#	#	#	
Comment							
§4.71a Rating	0%	0%	0%	0%	0%	0%	
* Within Function Limits (WFL)

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each hip condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB rated the bilateral hip condition 0% (coded 5019) citing no ratable limitation of motion.  The VA rated the left hip condition at 10% plus the right hip condition at 10% (5253-5019).  The VA cited full ROM and painful or limited motion of a major joint or group of minor joints.  There was no evidence of disability for consideration under 5250 (hip, ankylosis of), 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of), 5253 (thigh impairment of abduction, adduction, rotation of), 5254 (hip, flail joint), or 5255 (femur fracture nonunion/malunion of).  Members debated if 0% was warranted for the bilateral hips or if application of VASRD §4.40 (functional loss) or §4.59 (painful motion) justified a 10% rating.  The Board carefully considered the option of rating both hip conditions together, noting that the VA rated each hip separately.  The Board concluded that the evidence did not provide sufficient grounds for recommending separate hip disability ratings in this case, and that a bilateral rating of 10%, coded 5019-5003, is a good analogy to both the pathology and disability.  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 bilateral 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 DoDI 1332.39 for rating the ankle condition was operant in this case and the condition was adjudicated independently of that policy/instruction by the Board.  In the matter of the right ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral hip condition, the Board unanimously recommends a disability rating of 10%, coded 5019-5003 IAW VASRD §4.71a.  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	
Chronic Pain, Right Ankle	5009-5003	10%	
Bilateral Trochanteric Bursitis	5019-5003	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131231, 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 XXXXXXXXXXXXXXXXXXX, AR20160002089 (PD201400165)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA