RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  pd-2014-00755
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Telecommunications Operator-Maintainer) medically separated for bilateral hip pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “developmental dysplasia of hips” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions detailed in the chart below for PEB adjudication.  The Informal PEB (IPEB) adjudicated “chronic bilateral pain secondary to developmental hip dysplasia” as unfitting and rated at 0%.  The remaining conditions were determined to be not unfitting.  The CI appealed to the formal PEB (FPEB) but later waived the formal hearing and was medically separated.  

CI CONTENTION:  “The PEB rating was 0% prior to left hip surgeries.  Hip dysplasia is described as preexisting, however I did not have any issues prior to service.  I also went to medical several times and was told that everything was normal based on X-rays.  This condition is something that will continue until I can get a hip replacement.  Additionally, there is no mention of arthritis in the PEB, but it is described in the MEB.  Before the Army, I could physically do anything.  Now I am extremely limited in that I limp and can’t even run.  All of this has taken a tremendous toll on me physically and mentally.  Also the incisions from hip surgery still do not have feelings. (They are numb).”  

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:  

Admin IPEB – Dated 20061006	VA* - ~ 25 Months Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Pain Secondary to Developmental Hip Dysplasia	5054	0%	Left Hip Dysplasia, Postoperative	5024	10%	20090107	
			Right Hip Dysplasia, Postoperative	5024	10%		
Healing Right Femoral Osteotomy	Not Unfitting	No VA Placement	
Limb Length Discrepancy	Not Unfitting	No VA Placement	
Other x 0 (Not In Scope)	Other x 4	
RATING:  0%	COMBINED RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20090916 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Bilateral Hip Condition.  The PEB’s bilateral rating of 0% analogously to 5054 (hip replacement [prosthesis] prosthetic replacement of the head of the femur or of the acetabulum) does not comport with the VASRD §4.71a stipulation for a 30% minimum rating under this code.  Though rating by analogy, the surgical procedures performed were not consistent with either a prosthetic replacement of a femoral head, or acetabulum.  While the bilateral hip condition was not specifically implicated in the commander’s statement, it was profiled, deemed medically unacceptable by the MEB, and judged unfit by the PEB.  It remains that both hips were considered to fail retention standards.  Both hips underwent serial surgical interventions to address symptoms, and slow progression, of congenital (inborn physical abnormality or disease) and degenerative changes.  The right hip pathology was more severe and therefore treated earlier, than the left.  While dissimilar in severity, the fitness implications of the bilateral limitations were comparable.  Members agreed that the right and left hip conditions should be reasonably justified as separately unfitting.

Right Hip Condition.  The service treatment record (STR) documents that the CI developed right hip pain in basic training.  Serial imaging studies revealed pathological changes in the bilateral hip ball (femoral head) and socket (acetabulum) joints.  A pelvis CT showed bilateral hip dysplasia (abnormal growth or development), partially uncovered femoral heads, and boney fragments at the acetabular rims.  The CI complained of right hip clicking and pain, which limited her activities.  She was diagnosed with developmental dysplasia of the hip (DDH), and a right hip labral (ring of cartilage surrounding hip joint) tear, by imaging studies and physical exams.  The characteristics associated with DDH are abnormal hip joint formation, an unstable femoral head within the acetabulum, and ligamentous laxity.  The CI was counseled as to nonoperative and operative options, risks, and benefits.  She opted for staged operative therapy with stage one to repair the labral tear and stage two to correct the underlying dysplastic hip.  On 4 August 2005 the CI underwent right hip arthroscopy with labral repair and loose body removal.  On 12 October 2005, the CI underwent right acetabular and proximal femoral osteotomies (surgical procedures where bone is cut or excised to shorten, lengthen, or realign).  Post-operative imaging showed post-surgical changes and a surgical screw projecting into the hip joint and femoral head.  On 14 October 2005, the CI underwent an implant revision to remove the screw impinging on the femoral head.  Post-operative imaging showed interval repositioning of the surgical screw.  The narrative summary (NARSUM) by orthopedic surgery, 8 months before separation, recounted the history of DDH and interventions to date.  The CI reported her pre-operative pain had persisted but the recommended left hip arthroscopy and osteotomies had been deferred because she became pregnant.  Her hip pain increased during her pregnancy.  The physical exam revealed an abnormal gait (lurches to her right) and her right hemipelvis was about 2.5cm. lower than her left.  The right hip exam showed healed lateral thigh and iliac crest incisions.  The right hip was sore, and the left hip was mildly sore, with manipulation.  Lower extremity reflex, sensory, and motor exams were normal with the exception of hip abductor (right 3+/5, left 4/5) weakness.  The hip active range-of-motion (ROM) values by orthopedic surgery for the MEB are in the chart below.  The CI complained of constant hip pain (right 7/10, left 6/10), that interfered with sleep, and was worse with lying on her sides.  She reported avoiding medication because of her pregnancy, had been limping since August 2004, did not use a cane, and avoided walking for more than 5 minutes.  The diagnoses listed DDH (not acceptable), healing right femoral and periacetabular osteotomies (acceptable), and limb length discrepancy secondary to right femoral varus osteotomy.  The examiner reported the CI had residuals of congenital hip dysplasia, which was asymptomatic prior to enlistment, and became symptomatic in basic training because of increased physical activity.  He indicated had this condition been diagnosed prior to entry, she would have been unfit.  The goal of the right hip surgery was to improve femoral head coverage, relieve symptoms, and retard the development of arthritis.  Slowing the rate of arthritis progression was to lengthen the time to which one becomes a candidate for joint replacement.  Similar surgery, on an elective basis, was indicated on the left.  The surgeon opined that after full recovery from surgery, her ability to return to military service was unlikely.  

The CI refused the general medical compensation and pension (C&P) exam scheduled for the month before separation.  The C&P exam, 25 months after separation, recounted the history and interventions to date.  The CI complained of weakness, stiffness, lack of endurance, locking, fatigability, and sharp hip and back pain.  She denied swelling, heat, redness, giving way, and dislocation.  She reported pain of 7/10, ranging from 1-10/10, occurring two times per day, and lasting 1/2-hour.  Pain was characterized as squeezing and aching, exacerbated by physical activity, and relieved by rest.  The CI could function without medication and took over the counter pain medications as needed.  She reported functional impairment when on her feet for long periods and playing with her child.  The physical exam revealed a normal posture, an abnormal gait with a limp to the right, no assistive device for ambulation, and a leg length discrepancy (right 80 cm and left 82 cm).  Postsurgical scars were on the right anterior and lateral hip and left lateral hip.  The scars did not show tenderness, disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, or limitation of motion.  The hip exam showed guarding of movement bilaterally.  There was no edema, effusion, weakness, tenderness, redness, heat, or subluxation.  The hip ROM values are shown in the chart below.  The bilateral hip joint function was additionally limited by pain, following repetitive use, but there was no additional limitation in degree.  The joint function was not additionally limited, following repetitive use, by fatigue, weakness, lack of endurance, or incoordination.  The foot exam did not reveal any signs of breakdown, callosities, abnormal weight bearing, or unusual shoe wear pattern.  The hip X-rays showed evidence of bilateral congenital hip dysplasia with postsurgical changes and hardware.  The diagnosis listed bilateral hip dysplasia with residual scars.

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

Right Hip (Thigh) ROM
(Degrees)	MEB ~5 Mo. Pre-Sep
(20060405)	VA C&P ~25 Mo. Post-Sep
(20090107)	
Flexion (125 Normal)	90	90	
Extension (20)	0	20	
External Rotation (45)	50	60	
Abduction (45)	35	40	
Adduction (45)	23	15	
§4.71a Rating	10%	0%	
The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB, 2 months before separation, rated the bilateral hip condition 0% (VA code 5054; hip prosthetic replacement of the head of the femur or of the acetabulum).  The PEB cited chronic pain secondary to developmental hip dysplasia (existed prior to entry and permanently service aggravated), multiple surgeries, slightly decreased ROM, minimal leg length discrepancy, and an abnormal gait.  The VA rating decision (VARD), cited the C&P exam performed 25 months after separation, and rated the right hip condition 10% (5024; tenosynovitis).  The VARD cited pain secondary to developmental hip dysplasia, multiple surgeries, painful or limited motion of a major joint, ROM, pain with ROM, functional loss due to pain, and an abnormal gait.  Based upon the more proximate MEB exam, 8 months before separation, a 10% rating was justified under VASRD code 5251 (thigh, limitation of extension of).  There was no compensable limitation of motion for consideration under 5252 (thigh, limitation of flexion of).  There was no evidence of disability for consideration of rating under 5250 (hip, ankylosis of), 5253 (thigh impairment of abduction, adduction, rotation of), 5254 (hip, flail joint), or 5255 (femur fracture nonunion/malunion of).  The board assigned little probative value to the C&P exam because of the remote temporal relationship to the date of separation.  Board members agreed a 10% rating was justified IAW §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 recommends a disability rating of 10% for the right hip condition (5251).

Left Hip Condition.  The STR documents that the CI developed right hip pain in basic training and later developed milder left hip pain.  Serial imaging studies revealed bilateral hip dysplasia and pathological changes in the femoral heads and acetabula.  The left hip history, subjective complaints, and objective findings from the NARSUM are documented above under the right hip condition.  One week before separation, the CI underwent a left proximal femur varus derotational osteotomy (VDRO).  The goal of a VDRO is to restore normal anatomy, optimal joint congruency, and to inhibit degenerative hip deterioration.  This procedure was deemed the best option to equalize her leg length discrepancy created by the right hip surgery.  The postoperative pelvis X-ray showed postsurgical changes and no acute hardware complication.  The CI did well postoperatively and was discharged, three days before separation, with out-patient physical therapy.  The left hip history, subjective complaints, and objective findings from the post-separation C&P exam are documented above under the right hip condition. 

The left hip ROM evaluations 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 ~5 Mo. Pre-Sep
(20060405)	VA C&P ~25 Mo. Post-Sep
(20090107)	
Flexion (125 Normal)	110	80	
Extension (20)	0	20	
External Rotation (45)	30	60	
Abduction (45)	35	40	
Adduction (45)	30	15	
§4.71a Rating	10%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral hip condition 0% (5054).  The PEB cited chronic pain secondary to developmental hip dysplasia (existed prior to entry and permanently service aggravated), slightly decreased ROM, minimal leg length discrepancy, an abnormal gait, and radiographic left hip findings consistent with un-treated developmental hip dysplasia.  The VARD cited the C&P exam performed 25 months after separation, and rated the left hip condition 10% (5024).  The VARD cited pain secondary to developmental hip dysplasia, surgery, painful or limited motion of a major joint, pain with ROM, functional loss due to pain, and an abnormal gait.  The Board assigned little probative value to the more proximate MEB exam because it occurred before the left hip surgery.  Recognizing the remote temporal relationship, the board assigned higher probative value to the C&P exam because it occurred after surgery and a period of convalescence.  Based upon the C&P exam, there was no compensable limitation of motion for consideration under 5251 or 5252.  There was no evidence of disability for consideration of rating under 5250, 5253, 5254, or 5255.  Board members agreed a 10% rating was justified IAW §4.40 and §4.59 (functional loss and/or painful motion respectively).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3, the Board recommends a disability rating of 10% for the left hip condition (5024).

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 right hip condition, the Board unanimously recommends a disability rating of 10%, coded 5251 IAW VASRD §4.71a.  In the matter of the left hip condition, the Board unanimously recommends a disability rating of 10%, coded 5024 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: 

CONDITION	VASRD CODE	RATING	
Right Hip Pain Secondary to Developmental Hip Dysplasia	5251	10%	
Left Hip Pain Secondary to Developmental Hip Dysplasia	5024	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131229, with attachments
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, AR20160002767 (PD201400755)

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