RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00231
BRANCH OF SERVICE:  Army	BOARD DATE:  20150123
SEPARATION DATE:  20090925

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Basic Trainee) medically separated for left and right hip pain.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty although she was authorized to perform alternate physical fitness testing.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Chronic left hip pain due to residual of left femoral head stress reaction and chronic right hip pain due to femoral neck stress reaction were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded chronic bilateral knee pain as medically unacceptable.  No other condition was submitted by the MEB.  The Informal PEB adjudicated chronic left hip pain and chronic right hip pain as unfitting, rated 10% each, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The PEB performed an administrative correction to the Army PEB Form 199 but did not change the CI’s disposition.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I never saw a doctor.  I had injured knees and hips and had to walk up three flights of stairs several times a day.  We would be woke up for formations at midnight.  I had a top bunk that further injured me.  I had to work while put on bed rest.  I never received the proper treatment for my stress fracture in my hips and knees.  I was forced to do P.T. and run two miles after diagnosed with stress fractures and in return I injured myself again, but worse this time.”

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 Admin Correction IPEB – Dated 20090820	VA* - (~4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Hip Pain	5299-5255	10%	Left Femoral Neck Stress Reaction	5252	10%	20100115	
Chronic Right Hip Pain	5299-5255	10%	Right Femoral Neck Stress Reaction	5299-5252	10%	20100115	
Bilateral Knee Pain	Not Unfitting	Left Knee Patellofemoral Syndrome	5299-5260	10%	20100115	
		Right Knee Patellofemoral Syndrome	5260	10%	20100115	
Other x 0 (Not in Scope)	Other x 0	
Combined:  20%	Combined:  40%	
*Derived from VA Rating Decision (VARD) dated 20100217 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Chronic Left and Right Hip Pain Conditions.  According to the MEB narrative summary (NARSUM) evaluation 3 months prior to separation, the CI developed pain in her hips during physical training in September 2008.  Magnetic resonance imaging (MRI) studies in September 2008 confirmed stress reactions of the left femoral head and right femoral neck, and left trochanteric bursitis.  Thirty days of convalescent leave resulted in improvement in pain, but regression occurred when activity was increased.  X-rays in November 2008 were normal, and follow-up MRI evaluations in February and May 2009 indicated resolution of the left sided stress changes and improvement of the right sided stress changes with some persistence of marrow edema (swelling).  She could not complete basic training.  At the time of the NARSUM the CI complained of pain in both hips (right worse than left) every day made worse by lying on either side, climbing stairs or prolonged walking.  Pain flares could last 1 or 2 hours.  An anti-inflammatory medication provided partial pain relief.  Physical examination showed a normal gait and stance.  She dressed and undressed “without discomfort” and got “on and off the examination table without difficulty.”

At a VA clinic visit on 19 October 2009 (a month after separation), the CI stated she was having “mild hip pain now.”  At the VA Compensation and Pension (C&P) exam approximately 4 months post-separation, the CI reported there were no impediments to performance of activities of daily living.  She worked as a resort inspector and experienced flares of hip pain with climbing stairs, standing more than 10 minutes or moving any amount of weight.  Examination showed a normal gait without use of assistive devices.  Tenderness of the hips was in an anterior-lateral location.  

The goniometric range-of-motion (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.

Hip (Thigh) ROM
(Degrees)	NARSUM 3 Mos. Pre-Sep	VA C&P 4 Mos. Post-Sep	
	Left	Right	Left	Right	
Flexion (125 Normal)	115	115	35	35	
Extension (20)	2	10	20	20	
External Rotation (45)	> 20	> 20	20	20	
Abduction (0-45)	50	42	15	15	
Adduction (45)	Crossed leg over the other	Crossed leg over the other	20	20	
Comment	+Painful motion	+Pain limited ROM	
§4.71a Rating	10%	10%*	10%	10%	
*IAW §4.59 (Painful motion)

The Board directed attention to its rating recommendation based on the above evidence.  The PEB used an analogous 5255 code (femur, impairment of), and cited painful motion as a rationale for a 10% rating for each hip.  Based on the C&P exam showing considerably reduced flexion, the VA assigned a 10% rating for each hip under the 5252 coding pathway (thigh, limitation of flexion of).  Board members agreed that painful motion was reasonably conceded, and that the NARSUM exam also provided justification for a 10% rating of the left hip under the 5251 code (thigh, limitation of extension of).  The Board considered if the next higher 20% rating was justified under the 5255 code, but agreed that “moderate” hip disability was not described by the evidence.  There likewise was no evidence to support a higher rating for either hip based on limitation of flexion or abduction (the only motion parameters that allow for a rating greater than 10%).  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 chronic left hip pain condition and chronic right hip pain condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that bilateral knee pain was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Concurrent with the hip pain condition, the CI experienced pain in both knees.  Nuclear medicine imaging in September 2008 showed “overuse uptake” of both knees.  X-rays in March 2009 were unremarkable except for a “suggestion of disuse osteoporosis” (thinning bone from lack of use).  After failing an attempted training test in May 2009, her “hip and knee pain became worse.”  At the NARSUM exam she complained of pain in both knees every day, with flares from prolonged walking or climbing stairs.  Examination showed normal gait and stance.  She dressed and undressed “without discomfort” and got “on and off the examination table without difficulty.”  There was no knee tenderness, no guarding and no evidence of pain during ROM testing.  The NARSUM examiner stated that the CI could not return to basic training because of the hip and knee pain; and considered the bilateral knee condition to be medically unacceptable.  The commander’s statement did not specify any condition beyond “injury prevents her from returning to basic training.”  The permanent L3 profile on 15 June 2009 included chronic bilateral knee pain, and allowed walking at own pace and distance.  On the Report of Medical Assessment (DD Form 2697) on 16 June 2009 the CI indicated that her overall health was worse because of her hip condition, and because of a rash and a tooth problem.  The knee condition was not mentioned.  At a VA clinic visit on 19 October 2009, the CI stated that the knee pain “comes and goes.”  At the C&P exam 4 months after separation, the CI complained of knee pain caused by standing for 10 minutes, walking one flight of stairs, or moving weight.  Exam showed a normal gait.  The examiner rendered a diagnosis of bilateral patellofemoral syndrome.

After due deliberation, the Board majority agreed that the preponderance of the evidence with regard to the functional impairment of bilateral knee pain condition favors its recommendation as an additionally unfitting condition for disability rating. In this case a bilateral condition was determined to fail retention standards, was profiled, and was possibly implicated by the commander’s statement.  Member consensus was therefore that each knee should be conceded as separately unfitting.

The goniometric 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.

Knee ROM
(Degrees)	NARSUM 3 Mos. Pre-Sep	VA C&P 4 Mos. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	130	130	115	115	
Extension (0 Normal)	5*	0	0	0	
Comment	No evidence of pain	Pain limited ROM; +crepitus and tenderness 	
§4.71a Rating	0% or 10%**	0% or 10%**	10% (VA 10%)	10% (VA 10%)	
*Hyperextension
**Conceding §4.40 (functional loss) or §4.59 (painful motion)

Regarding a rating recommendation, Board members agreed that coding and rating features were logically identical.  Compensable limitation of motion was not present, but the Board considered if a 10% rating for painful motion (§4.59) or pain with use (§4.40) was justified.  Despite a painless examination recorded by the NARSUM, Board members debated if §4.40 should be conceded based on the reported history of pain, but the Board majority agreed there was insufficient support for this approach.  Therefore, a 0% rating was warranted for each knee.  Given the rating recommendation as just elaborated, the Board concluded that there is no benefit to the CI in unbundling and rating the bilateral knee condition.  Therefore, after due deliberation, in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral knee 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 matter of the chronic left hip pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right hip pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral knee pain condition, the Board by majority vote recommends no change from the PEB determination as not unfitting.  The single voter for dissent did not elect to submit a minority opinion.  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 20140103, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXXXX, AR20150008501 (PD201400231)

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