RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01015
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20070531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a traditional drilling Reserve E-3 (Motor Vehicle Operator) medically separated for right and left hip bursitis.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “other symptoms referable to joint of pelvic region and thigh” and “other disorder of muscle, ligament and fascia,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded one other condition (bilateral iliotibial band tightness) for PEB adjudication.  The MEB Board Proceeding and MEB NARSUM listed anorexia nervosa which was not included on the PEB Board Proceedings.  The Informal PEB (IPEB) adjudicated the right and left hip bursitis as unfitting, rated 10% and 0%, respectively.  The remaining condition was determined to be Category II, (contributing to unfit).  The CI made no appeals and was medically separated.  

CI CONTENTION:  “The applicant makes no specific contention in her application.  Her 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 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:  

IPEB – Dated 20070321	VA* - (~8 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bursitis, Greater Trochanter (Right)	5019	10%	Right Greater Trochanter Bursitis Status Post Stress
Fracture, Right Pelvis	5019-5252	10%	20080130	
Bursitis, Greater Trochanter (Left)	5019	0%	No VA Placement	
Bilateral Iliotibial Band Tightness	Cat II 	No VA Placement	
Other MEB/PEB Conditions x 1 (Not In Scope)	Other x 1 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20081016 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Greater Trochanter Bursitis.  The service treatment record (STR) documents a history of right hip and groin pain that developed without antecedent injury.  Serial hip X-rays between 2003 and 2007 were normal.  At a 27 January 2006 physical therapy (PT) encounter, the CI complained of right hip pain, mostly in the right groin region.  It was exacerbated by stair climbing, standing up from the floor, running on hard surfaces, and initiation of movement after long periods of sitting.  She reported she had been previously diagnosed with right hip bursitis (inflammation of fluid filled sacs between tissues) and a right inferior pelvis stress fracture (2003).  Palpation revealed Grade 2 tenderness at the right, and Grade 1 tenderness at the left greater trochanter (bony prominence on proximal lateral femur for muscle attachment).  The bilateral hip range-of-motion (ROM) was within normal limits except for mildly decreased internal rotation.  At the 29 August 2006 orthopedic surgery evaluation, the CI complained of a 4-year history of right groin pain with running, and a 2 to 3-year history of bilateral pain over the greater trochanters with exercise.  There was an associated snapping sensation in the right hip.  Right hip joint pain was exacerbated by activity (running, jumping, standing) and lying on the affected side.  Pain was relieved by rest and medications.  The CI denied hip joint stiffness and the hip did not “lock up.”  She has previously been treated for bilateral trochanteric bursitis (inflammation of the bursa at the lateral hip) with NSAIDS, corticosteroid (kenalog) injections, and PT.  She only attended one session of PT and then self-discontinued because of inability to take time off from her civilian job and schooling.  The musculoskeletal exam showed the CI to be diffusely lax, with hyperextension of multiple joints.  The bilateral hip exam revealed normal appearance with tenderness at both greater trochanteric bursae.  There was no joint instability and there was no pain elicited with motion.  Bilateral Ober's tests (assesses tightness or inflammation of the iliotibial band [lateral thigh connective tissue]) were positive and hamstring contracture tests were negative.  The bilateral hips demonstrated full ROM.  The diagnoses listed trochanteric bursitis and snapping hip syndrome.  The narrative summary (NARSUM) by orthopedic surgery, eight months before separation, recounted the history of right groin pain with running and bilateral pain over the greater trochanters with exercise.  The hip pain was located laterally and was exacerbated by sleeping on her sides.  The CI reported that approximately 3 years prior, she had been diagnosed with a right hip stress fracture.  This diagnosis was made without imaging (bone scan or MRI), and there was no significant improvement with rest.  The CI reported an occasional snapping sensation in the right groin with sit-ups and with running.  There had been no significant improvement with activity modification, rest, or corticosteroid injections and she was unable to participate in unit exercise.  The musculoskeletal exam revealed tenderness at the bilateral greater trochanters.  Bilateral Ober's tests were positive for tight iliotibial bands.  Snapping of the right hip, with associated pain, was noted when moving the hip from an abducted externally rotated position to and extended position.  The right hip demonstrated full ROM.  The diagnoses listed right snapping hip syndrome and bilateral iliotibial band tightness.  At the 5 March 2007 PT encounter, the CI denied right hip pain (0/10).  She reported she was able to stand for 2 hours, sit for 4 hours, walk for 2 hours, drive for 2 hours, and perform transfers without onset of symptoms.  The CI reported she had been compliant with her home exercise program and planned on continuing stretching and strengthening exercises to maintain strength and flexibility.  The treatments to the right hip and low back included moist heat, premodulated electrical stimulation, ultrasound, soft tissue mobilization, manual trigger point release, myofascial release, and lumbar, sacral, and pelvic balancing.  The physical exam revealed a normal gait without postural deviations.  Provocative diagnostic tests were negative.  Lower extremity strength (5/5) and sensation (light touch) were normal.  Right hip ROM values are in the chart.  The Compensation and Pension (C&P) exam, 8 months after separation, recounted the history and interventions to date.  The CI reported she developed right greater trochanter and groin pain, without antecedent injury.  The condition had been stable; she had not been taking medications, and had not been seeking medical care.  The CI complained of flare-ups of 5/10 pain, three times a week, lasting minutes.  She was unable to run or stand for long periods and developed right hip pain after walking four blocks.  She reported being unable to sleep on her right side and having difficulty getting out of bed.  Her daily activities were mildly affected, but she was able to do normal activities (squatting and stair climb).  The physical exam noted a normal gait without assistive device.  The right hip exam revealed right groin tenderness but no greater trochanteric bursa tenderness.  The right hip demonstrated full ROM with pain at extreme flexion of the right hip.  After three repetitions of motion, there was no additional limitation of motion.  The major functional impact was pain rather than weakness, fatigue, or incoordination.  There were no sensory or motor deficits.  The diagnoses listed status post right pelvis stress fracture and right greater trochanter bursitis.

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

DOS 20070531
Right Hip (Thigh) ROM
(Degrees)	MEB ~8 Mo. Pre-Sep
(20061003)	PT ~3 Mo. Pre-Sep
(20070222)	VA C&P ~8 Mo. Post-Sep
(20080130)	
Flexion (125 Normal)	125 	120	125 	
Extension (20)	#	20 	20 	
External Rotation (45)	45 	45 	45 	
Abduction (45)	45 	45	44	
Adduction (45)	#	30	25	
Comment	AO	AO	AO	
§4.71a Rating	#%	0%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB, 2 months before separation, rated the bilateral hip condition (VA code 5019; bursitis) at 10% (right 10% + left 0% + bilateral factor).  The listed Category II condition (bilateral iliotibial band tightness) was considered to contribute to the unfitting bilateral hip condition.  The IPEB rated the right hip condition 10%, coded 5019.  The VA Rating Decision (VARD) cited the C&P exam performed 8 months after separation, and rated 10% coded 5019-5252 (bursitis-thigh, limitation of flexion of) for the right hip condition.  The VARD cited right hip pain, flare-ups, right groin tenderness, and pain with ROM.  Based upon the proximate exams (PT and C&P), there was no compensable limitation of motion for consideration under 5251 (thigh, limitation of extension of) or 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).  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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right hip condition.

Left Greater Trochanter Bursitis.  While the STR frequently documented bilateral hip (R>L) complaints, the overwhelming majority of subjective complaints, objective exam findings, radiographic imaging, and interventions were related at the right hip.  Interventions to ameliorate the more severe right hip pathology, concurrently treated the left hip.  An isolated reference characterizing left sided complaints “right-sided hip pain, also somewhat on the left side” was found in a clinical encounter.  While right hip clinical histories, focused exams, and ROM measurements were routinely performed, the left hip was frequently absent from the histories and physical exams.  The only proximate exam measuring left hip ROM was the PT encounter which recorded full ROM.  Specifics concerning the left/bilateral hip condition are detailed above under the right greater trochanter bursitis.  

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB rated 0%, coded 5019 for the left hip condition.  The VARD did not find service connection, or grant an evaluation, for the left hip condition.  Based upon the proximate PT 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.  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.  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 and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140204, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 4 Jan 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXX former USMC  
- XXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USMC 
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USMC
- XXXXXXXXXXXXXXXXXXXX former USN

						  XXXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)