RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-01156
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20080506	 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E3, Basic Trainee, medically separated by the Informal Physical Evaluation Board for right hip pain; with a disability rating of 10%.  

CI CONTENTION:  The CI contends for a higher hip rating, citing the disparity between the Service and VA ratings, and also references a lumbar condition.  The applicant’s 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 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 - 20080314	VARD – 20081120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Hip Pain ...	5099-5003	10%	Residuals Fracture, Right Femoral Neck 	5252	40%	20081021	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Right Hip Condition.  The narrative summary (NARSUM), supplemented by the outpatient service treatment record (STR), documented a sudden onset of right hip pain in basic training 2 months after the CI’s entry on active duty (9 months pre-separation).  He was diagnosed with a non-displaced stress fracture of the femoral neck which was managed conservatively.  The CI was not, however, able to resume the rigors of completing basic training and continued military service.  There are scant STR clinical entries given the timeline to separation, but there are none at odds with the NARSUM evidence.  Formal range-of-motion (ROM) measurements for the MEB are charted below, as are some repeat measurements on the eve of separation after the NARSUM.  The MEB’s DD Form 2808 recorded a non-specific decrease in passive ROM without further elaboration.

The NARSUM was conducted 5 March 2008 (2 months pre-separation) and documented constant hip pain “with very little improvement,” limiting “walking to 200 meters ... [and worsened by] repeated use.”  The NARSUM physical examination recorded a normal gait, joint tenderness, the absence of atrophy, and 5/5 strength of all proximal muscle groups.  The NARSUM ROM measurements are charted below.

A VA Compensation and Pension (C&P) examination was conducted 21 October 2008 (6 months post-separation) and documented that the “pain has become progressively worse ... cannot walk long distance ... [or] stand for a prolonged period of time.”  It noted that the CI was a full time student experiencing difficulty with prolonged sitting.  The VA physical examination recorded a normal gait, without comment regarding specific joint findings or strength.  The VA measured ROM measurements are charted below.  The examiner annotated various degrees of “functional loss due to pain” (presumed to be estimated since repetitions were not documented), which in many planes resulted in a negative ROM and in some conflicted with the pain thresholds specified in degrees; thus, it is difficult to interpret them as DeLuca deductions.  

The ROM evaluations referenced above, which the Board weighed in arriving at its rating recommendation, are summarized in the chart below.

Right Hip ROM
(Normal/Minimum 10%)	MEB PT
~3 Mo. Pre-Sep	NARSUM
~2 Mo. Pre-Sep	Repeat PT
1 Day Pre-Sep	VA C&P
~6 Mo. Post-Sep	
Flexion (125⁰/45⁰)	80⁰	100⁰	100⁰	20⁰ 	
Extension (20⁰/5⁰)	10⁰	20⁰	20⁰	10⁰	
External Rotation (45⁰/15⁰)	20⁰	-	-	20⁰	
Abduction (45⁰/10⁰)	10⁰	40⁰	40⁰	15⁰	
Adduction (45⁰/~10⁰)	10⁰	-	-	10⁰	
§4.71a Rating*	10%	10%	10%	30%**	
*   Conceding painful motion if minimum compensable not supported.   
** For flexion; remaining planes do not rate > 10%.  The VA rationale for 40% explained below.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating analogous to 5003 (degenerative arthritis) was consistent with VASRD §4.71a criteria for the Service ROM evidence and other ratable findings, specifically referencing VASRD §4.59 (painful motion).  The VA’s 40% rating under 5252 (limitation of flexion) cited limitation of flexion to 10 degrees, which is the 40% threshold for the code.  It is assumed that the examiner’s “functional loss” language, as elaborated above, was taken as a 10% deduction from the measured 20 degrees (itself a 30% criterion under 5252).  Other than the VA C&P evidence for flexion, there is no ROM evidence in this case which would support a rating higher than 10%; and, no ankylosis, flail joint, or instability that would achieve a rating higher than 10% under any alternate code.  The Board considered analogous rating under 5299-5255 (femur, impairment of) which offers ratings for contiguous hip disability: 20% for “moderate” and 30% for “marked.”  Members agreed, however, that considering the functional evidence in this case (normal gait, documented limitations), a higher rating would not be supported by this option.   There is a disparity in this case between the Service and VA ROM findings with obvious implications for the Board's rating recommendation.  The Board deliberated the probative value of these conflicting evaluations, with review of the overall evidence for corroboration.  Members agreed that the Service ROM evidence carried the determinant probative value because the Service ROM evidence was consistent and mutually corroborated, and the VA flexion evidence (required to carry a higher recommendation) is fairly assessed as an outlier.  Furthermore the Service evidence is more temporally proximate to separation and the VA examiner indicated that the condition was worsening after separation.  The clinical acuity (uncomplicated stress fracture) and functional capabilities (as above, including normal gait) are also not consistent with the severe ROM limitation presented in the VA C&P examination.  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 of the right 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.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140307, 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, AR20160003632 (PD201401156)

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