RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00733
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080417

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Basic Trainee, medically separated for “stress fractures, bilateral inferior pubic rami,” with a disability rating of 10%.

CI CONTENTION:  The CI was not evaluated for all conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20080321	VARD - 20090121	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fractures, Bilateral Inferior Pubic Rami	5099-5022	10%	Pubic Rami Stress Fracture/L Hip	5252-5022	10%	20081202	
			Pubic Rami Stress Fracture/R Hip 	5252-5022	10%	20081202	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Stress Fractures, Bilateral Inferior Pubic Rami.  The narrative summary (NARSUM) related the onset of pelvic pain during the fourth week of basic training which worsened despite restricted activities and physical therapy (PT).  An initial bone scan performed on 2 August 2007 confirmed stress fractures of the left pelvis (inferior and superior pubic rami).  There were no other hip or pelvic abnormalities seen on the scan.  Seven weeks later on 21 September 2007, the CI reported being pain free and special tests of heel percussion and hip compression were non-painful (normal).  Repeat radiographs performed on 5 December 2007 revealed healed left-sided pelvic stress fractures as well as a newer healing right-sided pelvic stress fracture.  A physical therapy (PT) evaluation dated 8 January 2008 indicated the CI “…still had pelvic pain”; no specific side was identified and she was referred to an MEB.  Her permanent profile listed chronic pelvic pain secondary to bilateral IPR stress fracture as one of three musculoskeletal conditions.  The NARSUM was conducted on 26 February 2008 (2 months prior to separation) whereby the CI complained of a constant 3/10 pelvic pain that was exacerbated by prolonged standing or with increased activities.  She was not taking any medication for her condition.  Her physical examination (PE) noted a normal gait, decreased range-of-motion (ROM) of her hip and diffuse tenderness through both lower extremities from the hip to her ankles.  The examiner noted that the CI’s “pain is out of proportion to any exam findings.”  PT measured ROM (a month prior to NARSUM) revealed decreased and painful motion of both hips with a minimum of 85 degrees of flexion (normal 125 degrees; minimal compensable 45 degrees) and right hip extension of 2 degrees (normal 20 degrees; minimal compensable 5 degrees).  Her hip abduction and external rotation were not limited to minimal compensatory VASRD criteria and there was no comment in regards to limiting adduction of either hip.  Repeat X-ray results were stated as “Radiographs of the AP [anterior/posterior] pelvis today shows healed bilateral IPR stress fractures.”  At the VA Compensation and Pension (C&P) examination performed on 2 December 2008 (8 months after separation), the CI reported that her hip discomfort was about the same as it was in the military with intermittent pelvic pain and constant pain in her right-sided hip/groin.  She was able to perform activities of daily living (ADL’s) with periods of rest when performing housework.  Her PE revealed a normal gait, decreased and painful motion of both hips, and tenderness about the low pelvis bilaterally.  The ROM measurements of both hips were VASRD non-compensable except for adduction of 10 degrees on the right and 20 degrees on the left. 

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous 5099-5022 code (periostitis) citing painful motion.  The VA assigned 10% ratings for each hip using the analogous 5252-5022 (limitation of flexion-periostitis) based on the VA C&P examination 8 months after separation, citing painful or limited motion of a major joint.  Board members first deliberated if the left and right pelvic area/hips, having been de-coupled from the combined PEB adjudication, remained separately unfitting and therefore subject to a Service rating.  The overwhelmingly objective clinical STR evidence, as well as X-ray findings was solely representative of bilateral ‘pelvic’ stress fractures and not actual hip pathology.  Board members deliberated and agreed that the initial injury that rendered her incapable of performing military duty was indeed a single-sided condition (left pelvic stress fracture) that later became a bilateral condition (left and right pelvic stress fracture) and therefore, either side of a pelvic stress fracture would constitute a separately unfitting condition.  Next, members deliberated on relevant exam probative value (PV) and agreed that the NARSUM evaluation be given near exclusive PV due to its close time reference to the date of separation.  Members extensively deliberated over the apparent inconsistencies between the CI’s subjective complaints and objective physical/radiographic findings at the MEB exam and concluded that the clear radiographic evidence of healed fractures coupled with the provider’s comment of “pain being out of proportion to exam findings” would equate to no positive impairment rating.  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’s adjudication for the pelvic stress fracture condition.

BOARD FINDINGS:  In the matter of the bilateral pelvic 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.  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 20140206, 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 XXXXXXXXXXXXXXXXXX, AR20160005815 (PD201400733)

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