RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-00484
BRANCH OF SERVICE:  Army	BOARD DATE:  20141104
SEPARATION DATE:  20070907

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard PFC/E-3 (74D/Chemical Operations Specialist) medically separated for stress fracture, left femoral neck completed.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The left femoral neck completed stress fracture condition, was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “left femoral neck completed stress fracture” as unfitting, rated 10% referencing the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Condition has significantly worsened due to condition.  Sometimes in great pain, unable to sit for long periods of time.  Stand for long periods of time or even walk for long.  Do not have good range-of-motion (ROM).  Would like for VA to take some new X-rays and check for further injuries.  I could not have X-rays done last time because I was pregnant.”

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 stress fracture condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20070820	VA - (8 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fracture, Left Femoral Neck Completed	5099-5003	10%	Status Post ORIF of Left Hip…	5299-5255	10%	20080511	
			Residual, Scar of Left Thigh…	7805	0%	20080511	
Other x 0  (Not in Scope)	Other x 2 	20080511	
Combined:  10%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20080529 (most proximate to date of separation)

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  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 the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

Left Hip Condition.  The service medical records showed that the CI experienced left hip pain at the end of basic training in May 2007.  A 10 May 2007 nuclear medicine bone scan showed a left medial femoral neck stress fracture.  The 18 May 2007 emergency medicine encounter documented a compression stress fracture involving about 70% of the left femoral neck.  On 25 May 2007, the CI fell and sustained a completed left femoral neck fracture.  Orthopedic surgery performed a closed reduction of the fracture and placed a dynamic hip screw (DHS) for internal fixation.  On 10 July 2007 (6 weeks after surgery), physical therapy measured ROM for the MEB.  Goniometer measured ROM is summarized in the chart.  The CI underwent the MEB history and physical the following day.  She reported continued pain and the hip surgery.  A scar was noted over the left lateral hip, but no further details were provided.  X-ray images were contraindicated as a pregnancy test obtained for the MEB physical was positive.

The 30 July 2007 MEB narrative summary (performed 2 months prior to separation), was dictated by an orthopedic surgeon.  The CI reported that despite convalescent leave and physical therapy, she continued to have left hip and thigh pain which limited physical activity.  Physical examination of the left hip revealed a well healed incision on the lateral aspect.  There was mild tenderness with light palpation and a deep muscle ache with deep palpation.  Mild pain was elicited with forced flexion.  Standing on her left leg caused thigh pain with radiation toward her knee.  Muscle strength was 4+ out of 5 in all distributions.  The action officer opined that this is an expected finding in the immediate post-operative period and consistent with being non-weight bearing to allow healing.  Neurovascular elements, motor functions and light touch sensation were intact.  ROM as measured by physical therapy with a goniometer is charted below.  The diagnosis was listed as left femoral neck completed stress fracture with no further surgeries warranted.

VA Compensation and Pension examination dated the 11 May 2008 (performed 8 months after separation), the CI complained of persistent left hip, thigh and knee pain exacerbated by cold weather, prolonged sitting and walking.  The CI reported she was independent in activities of daily living.  She did not report additional limitation following repetitive use or during flare-ups and did not report incapacitating episodes during the past 12-months.  She did not use a brace or assistive device and had a normal gait on examination.  Physical examination of the left lower extremity demonstrated a well-healed surgical incision on the lateral thigh which was mildly tender to palpation.  The ROM is summarized in the chart below and uncomfortable at the ends of motion.  Following five repetitions of ROM, the pain in the hip and thigh remained the same without evidence of decreased ROM, fatigue, weakness or lack of endurance.  The 11 May 2008 left hip and femur X-ray images showed intact fixation hardware, no acute displaced fracture or dislocation and no evidence of traumatic injury.  The examining physician’s impression was chronic left lower extremity pain likely secondary to strain status post surgery of left femoral neck stress fracture.  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.

Left Hip (Thigh) ROM
(Degrees)	MEB ~ 2 Mos. Pre-Sep	NARSUM Five weeks Pre-Separation 	VA C&P ~ 8 Mos. Post-Sep	
	Right	Left			
Flexion (125 Normal)	110	95	120	95	
Extension (20)	10	5 (15 PROM)	15	10	
External Rotation (45)	---	45	35	
Abduction (0-45)	35	20	45	35	
Adduction (45)	---	30	25	
Comment	Extension Limited by Weakness	Continued PT recommended	DeLuca Negative	
§4.71a Rating	10%	0%	0%	

The Board directs its attention to its rating recommendation based on the above evidence.  The PEB rated the left hip condition 10% VASRD code 5099-5003, analogous to degenerative arthritis, IAW USAPDA pain policy.  The VA also rated the left hip condition at 10% using the VASRD code 5299-5255 (analogous to femur), impairment of, with slight knee or hip disability.  Board members agreed a 10% rating was justified IAW §4.40 (functional loss) and §4.59 (painful motion).  The ROM limitations do not support a higher rating and absent the inability to cross her legs or limitation of out-toeing to 15 degrees, the Board found no route to a higher rating.  The Board noted that the left hip condition might be more appropriately coded under 5252 (thigh, limitation of flexion) or 5255, but neither code affords an advantage to the CI.  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 left 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 for rating the left hip condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the left hip 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 20140519, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXX
President
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 XXXXXXXXXXXXXXXXX, AR20150006246 (PD201400484)

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