RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-00354	
BRANCH OF SERVICE:  AIR FORCE  	SEPARATION DATE:  20040824

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Fire Protection) medically separated for bilateral lower extremity conditions.  The bilateral leg condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was issued an L4 profile and referred for a Medical Evaluation Board (MEB).  The bilateral lower leg condition, characterized as “avascular necrosis of the femoral head, grade IV C/2” and “avascular necrosis of the femoral head, grad IV B/2, were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “left lower extremity avascular necrosis of left femoral head” and “right lower extremity avascular necrosis of right femoral head” as unfitting, rated 10% and 10%, referencing application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) and DoD guidelines.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI contends his condition has had a significant impact on his activities of daily living and employment.  The 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 20040628	VA - (1 Week Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LLE Avascular Necrosis …	5255	10%	Left Idiopathic Vascular Necrosis…	5011-5255	20%	20040901	
RLE Avascular Necrosis …	5255	10%	Right Idiopathic Vascular Necrosis…	5011-5255	20%	20040901	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 7	20040901	
Combined:  20%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20090428 (Original VARD is not in evidence or available).  

ANALYSIS SUMMARY:  

Bilateral Lower Extremities Avascular Necrosis of Femoral Heads.  The CI first developed hip pain in 2001 and was subsequently diagnosed with bilateral avascular necrosis of the hips.  This was treated surgically on the right on 1 May 2003 and the left on 22 July 2003.  He underwent rehabilitation, but was not able to return to full duty.  He was evaluated by the treating orthopedist on 3 May 2004, 12 and 9 months after surgery of the right and left hips, respectively, and noted to have slight pain on the right and moderate pain on the left.  He used an exercise bike at a low tension setting.  On X-ray, he had good repair bilaterally, but was thought that a total hip replacement within 5 years was likely.  He was able to walk about 1/2-mile.  The narrative summary (NARSUM) was dated 2 June 2004, just less than 3 months prior to separation.  The CI was noted to ambulate well, but with a limp.  He continued to have bilateral pain, more so on the left.  On examination, the surgical sites were well healed.  The range-of-motion (ROM) was reduced as charted below.  At the VA Compensation and Pension (C&P) examination performed on 1 September 2004, 1 week after separation, the CI reported that he could walk 1/2-mile most days and used a rail when climbing stairs; if he exceeded these limits, he had hip pain.  He was almost pain free with relatively normal function.  He was a full-time student and had no impairment with this from the hip condition.  On examination, he had a normal gait (also recorded as a free and easy gait with a slight limp) and posture with slight external rotation of both lower extremities.  The scars were well healed.  The ROM was reduced as charted below.  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.

B Hips (Thigh) ROM
(Degrees)	MEB ~ 2.75 Mo. Pre-Sep	VA C&P ~ 1 Week Post-Sep	
	Left	Right	Left	Right	
Flexion (125 Normal)	110	100	90	100	
Extension (20)	---	60			
External Rotation (45)	60	---	60	60	
Abduction (0-45)	60	60	30	45	
Adduction (45)	---	---	20	20	
Comment	Discomfort w/ some motion	Pain when walking over ½ mile	
§4.71a Rating	10% each (painful motion)	10% each (painful motion)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the hip condition at 10% each, coded 5255 (impairment of the femur).  The VA rated each at 20%, using the 5255 code and also 5011 (caisson disease [decompression injury]).  The Board considered the evidence.  The difference between a 10% and 20% rating using the 5255 code is slight vice moderate disability.  The gait was recorded as both being normal a week after separation.  He had pain if he walked more than 1/2-mile or climbed stairs without a rail, implying that he did not have pain if he stayed within these limits.  He was a student and reported no limitations in this from the hip condition.  The Board determined that this is better described as a mild impairment than moderate.  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.  

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 femoral head avascular necrosis 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, as follows:  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140106, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00354.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings