RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01306
BRANCH OF SERVICE:  NAVY	SEPARATION DATE:  20080401

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Trainee) medically separated for closed left femur fracture status post intramedullary nailing and trochanteric bursitis of the left hip, each rated at 10%, with a combined disability rating of 20%.  

CI CONTENTION:  The CI contends that he was only rated for conditions related to his surgery and not for other related conditions.  His 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 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 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 20080128	VA* - (~4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Closed Left Femur Fracture S/P Intramedullary Nailing	5255	10%	Left Hip Fracture S/P Left Hip Surgery with Residual Scars and Limitation of Range of Motion**	5255	10%	20080808	
Complication Due to Orthopedic Device Implant	Cat II					
Trochanteric Bursitis of the Left Hip	5099-5003	10%					
Trochanteric Pain Secondary to Proximal Interlocking Screws	Cat II					
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 8	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20081003 (most proximate to date of separation (DOS)). 
**Claimed as “left leg pain, weakness, lack of mobility, trochangeric bursitis, left hip, closed left femur fracture and tender scars”.  

ANALYSIS SUMMARY:  

Closed Left Femur Fracture S/P Intramedullary Nailing Condition.  The service treatment record indicated the CI was a back seat passenger in a one car motor vehicle accident on 31 May 2006 when he was ejected from the vehicle and sustained a left femur fracture.  On arrival at the Emergency Department, the CI was stable with a deformity of the proximal left femur, which was neurovascularly intact.  X-rays confirmed the proximal femur fracture.  Other than a blow-out fracture of the left orbit, the emergency imaging studies were negative.  Later that day, the CI underwent surgery consisting of a left femoral intramedullary (IM) nailing for the left comminuted proximal one-third femoral shaft fracture.  Post procedure X-rays confirmed the IM rod had been placed in a good position; the comminuted fracture was reduced; and a large medial butterfly fragment remained detached.  The CI’s postoperative course was benign and he was given Percocet (a combination of oxycodone, a narcotic and acetaminophen, a pain reliever) and Naprosyn (naproxen, a nonsteroidal anti-inflammatory drug (NSAID)) for pain.  He was referred to a facility for acute stepdown care for physical therapy, which was carried out through 11 July 2006.  Orthopedic evaluation on 13 July 2006 indicated the CI was doing very well and had completed full weight bearing with a cane and no longer need narcotic medication for pain.  There was no misalignment of the thigh and no swelling, but there was quadriceps atrophy.  Flexion was 120 degrees and extension was -5 degrees; and, motor strength of the hip and knee was normal.  X-rays of the hip were normal; X-rays of the left femur demonstrated initial healing of the fracture with good alignment and rotation; and X-rays of the left knee showed distal screws in good position.  After convalescent leave, the CI resumed physical therapy in August 2006 that continued through August 2007 when he reported anterior left knee joint pain, which was worse with activity including climbing stairs.  By February 2007, his leg was feeling better and he was able to lie on his left side to sleep, but he woke up numb or with hip or knee pain.  Running exacerbated the pain, but the CI continued to jog on the treadmill, but it still hurt; and, stair climbing was less painful.  Left hip pain was elicited by various motions (see below) in July 2007.  

Limited duty (LIMDU) for a closed fracture of the femur was issued on 13 July 2006 with limitations of no running, no physical readiness training, no command physical training, no squatting, no twisting motion, no heavy lifting, and no operational duty.  The STR indicated that the CI had an additional LIMDU in December 2006, which limited heavy lifting, but permitted him to run at his own pace.  A third LIMDU was requested and was pending

The MEB narrative summary (NARSUM) dated 8 November 2007 indicated the CI did not have an antalgic or Trendelenburg (lurch due to weakness of the gluteus muscles) gait.  His left hip and buttock area showed well-healed surgical scars as well as scars down along the lateral left knee.  The CI had no soreness or tenderness to palpation to the mid to proximal thigh, but was noted to have palpable tenderness along the trochanteric bursa, particularly with internal and external rotation.  The left hip ROMs were flexion 125 degrees, extension 5 degrees, internal rotation 45 degrees, and external rotation 45 degrees.  X-rays in November 2007 showed a healed mid proximal shaft femur fracture with a stable IM nail implant along with interlocking screws both proximally and distally.  At the MEB examination dated 20 November 2007, the CI reported on DD Form 2807-1 he had metal rods and screws in the left femur for a “fractured and cracked left femur”.   On 27 November 2007, the MEB physical examiner noted only the scars of the left hip (15 cm) and left knee (2 cm).  The non-medical assessment dated 26 November 2007 indicated the member did not have good potential for continued service in his present physical condition.  The CI did not believe there was much room for improvement in the medical condition of his leg.  

At the VA Compensation and Pension (C&P) examination dated 8 August 2008, performed 4 months after separation, the CI reported pain due to an orthopedic device implant for a fractured left femur with associated weakness, giving way, lack of endurance, locking and fatigability.  Pain in the knee occurred constantly and was described as aching, sharp, and cramping with a severity 6/10 (10 being the worst pain).  Treatment consisted of OxyContin (oxycodone, a narcotic) and Naprosyn (naproxen, a nonsteroidal anti-inflammatory drug (NSAID).  Functional impairments included running and prolonged sitting.  On examination there was tenderness and crepitus (grinding sensation) with no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding.  ROM measurements were left knee flexion 125 degrees and extension 0 degrees. Joint function on repetition was limited by pain.  The anterior and posterior cruciate ligaments were stable, but the medial and lateral collateral ligaments were abnormal with slight instability.
  
The 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 Knee ROM
(Degrees)	NARSUM~5 Mo. Pre-Sep
	VA C&P ~4 Mo. Post-Sep
	
Flexion (140 Normal)	Full	125	
Extension (0 Normal)	Full	0	
Comment	No pain with full flexion/extension	Joint function was limited by pain on repetition; slight instability of the medial and lateral collateral ligaments.	
§4.71a Rating	-	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The Navy PEB assigned a 10% rating using code 5255 (Femur impairment) for the Category I closed left femur fracture status post intramedullary nailing condition.  Additionally, the PEB determined a complication due to orthopedic device implant with left knee pain to be a Category II condition that is related to the Category I condition.  The VA assigned a 10% rating using code 5255 for the left hip fracture status post left hip surgery with residual scars and limitation of ROM (claimed as left leg pain, weakness, lack of mobility, trochanteric bursitis, closed left femur fracture, and tender scars) (see below).  The Board sought a route to a higher rating by focusing on the whether there was more than a slight knee or hip (discussed below) disability.  It should be noted that the VA assigned a separate 10% rating for left knee internal derangement using code 5257 based on slight lateral instability, but examinations prior to separation did not indicate any instability.  After a review of clinical documentation, the Board could not find evidence to support a moderate femur impairment disability; therefore, the Board was unable to come up with a route to a higher rating.  The Board then discussed and determined that the Category II condition did indeed result from, contribute to, and is related to the Navy Category I condition, which when rated did encompass the knee pain that by itself did not rise to an unfitting condition.  It is not separately unfitting and the rating for the knee is incorporated in the PEB’s use of code 5255 for the Category I condition.  

Trochanteric Bursitis of the Left Hip Condition.  The narrative summary (NARSUM) noted that after the CI completed his postoperative physical therapy, he complained of trochanteric pain, mostly when sleeping on the left side.  He had an episode of sharp pain in the trochanteric and hip regions with external rotation of the hip.  However, he had been able to run on a treadmill for less than 1/2-mile and did not report any mechanical type symptoms of the left hip.  On examination his left hip and buttock area showed well-healed surgical scars.  He had no soreness or tenderness to palpation to the mid to proximal thigh.  The left hip ROMs, as noted above, were flexion 125 degrees, extension 5 degrees, internal rotation 45 degrees, and external rotation 45 degrees.  The CI had palpable tenderness along the trochanteric bursa, particularly with internal and external rotation.  It was suggested the pain might improve with hardware removal.  However, because of the potential risks weighed against the benefits, the CI was advised to continue strengthening the left hip and opt for trochanteric injections to improve pain periodically.  The CI’s limitations included no shipboard duty, no submarine duty, no repetitive squatting, and no work in confined spaces.   

At the VA Compensation and Pension (C&P) examination dated 8 August 2008, performed 4 months after separation, the CI reported the condition was due to the injury to the femur, which was sustained as a result of a motor vehicle accident in 2006.  He did not have symptoms of swelling, heat, redness, giving way, lack of endurance, locking, fatigability and dislocation.  Left hip pain occurred constantly and travelled to the left femur.  The pain was aching, sharp and cramping.  The pain level was 9/10 and was elicited by physical activity.  Treatment consisted of Oxycontin and Naprosyn.   ROM measurements of the left hip were flexion 85 degrees, extension 30 degrees, adduction 25 degrees, abduction 45 degrees, external rotation 40 degrees with pain at 40 degrees, and internal rotation 40 degrees with pain at 40 degrees.  On repetition pain limited joint function by 15 degrees. 

The 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)	NARSUM ~5 Mo. Pre-Sep
	VA C&P ~4 Mo. Post-Sep
	
Flexion (125 Normal)	125	85	
Extension (20)	5	30	
External Rotation (45)	45	40	
Abduction (0-45)	-	45	
Adduction (45)	-	25	
Comment	Palpable tenderness along the trochanteric bursa particularly with internal and external rotation of the hip.	External rotation with pain at 40 degrees pain on repetition; pain limited joint function by 15 degrees.	
§4.71a Rating	PEB 10%	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The Navy PEB assigned a 10% rating using code 5099-5003 for Category I trochanteric bursitis of the left hip.  The PEB determined the trochanteric pain secondary to proximal interlocking screws was a Category II condition.  The VA assigned a 10% rating using code 5255 for left hip fracture status post left hip surgery with residual scars and limitation of ROM (claimed as left leg pain, weakness, lack of mobility, trochanteric bursitis, left hip, closed left femur fracture and tender scars).  The Board sought a route to a higher rating, but was unable to do so in the absence of ankylosis, limitation of flexion, abduction, adduction, and rotation, a flail hip joint, and moderate or marked hip disability.  The Board determined the Category II condition did in fact contribute to the Category I condition, but was not separately unfitting or ratable.  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 Navy Category I trochanteric bursitis condition and the Category II trochanteric pain secondary to proximal interlocking screws contributed to and is related to the  Category I 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 Category I closed left femur fracture status post intramedullary nailing  condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication nor any change in the Category II complication due to orthopedic device implant with left knee pain.  In the matter of the Category I trochanteric bursitis of the left hip condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication nor any change in the Category II trochanteric pain secondary to proximal interlocking screws condition.  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 20140310, 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 1 Feb 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:

- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN   
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC 

			XXXXXXXXXXXXXXX
	     		Assistant General Counsel
			(Manpower & Reserve Affairs)