RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01493
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Patriot Fire Control Operator, medically separated for “chronic right hip pain due to impingement,” with a disability rating of 10%.  

CI CONTENTION:  The CI believes he also should have been rated on his abdomen which “was ripped open in surgery.”  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 – 20081017	VARD – 20090629	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Hip Pain Due to Impingement…	5099-5003	10%	Right Hip Condition	5019	10%	20081114	
Abdominal Pain	Not Unfitting	Abdominal Scar	7804	10%	20081114	
		IBS with GERD and Fatty Liver	7319-7346	0%	20081114	
GERD	Not Unfitting					
		Residuals, Abdominal Compartment Syndrome	7399-7310	NSC	20081114	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Hip Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hip pain condition began around July 2007 while training.  The CI underwent right hip surgery (arthroscopy) in March 2008, 10 months prior to separation, for worsening right hip pain and snapping.  Surgery noted cam (femur) and pincer (acetabulum – socket) impingement abnormalities and decompression was performed in addition to a capsulotomy and psoas tenotomy (NOTE:  there were abdominal complications from the surgery which will be discussed below).  Despite treatment, the right hip condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “right hip femoral acetabular impingement status post right hip arthroscopy and decompression complicated by an abdominal compartment syndrome” for PEB adjudication.  

At the MEB examination dated August 2008, 5 months prior to separation (4 months after surgery), the CI reported right continued right hip pain and snapping.  Physical examination showed a slightly antalgic gait favoring the right leg with “near full range of motion of his right hip with pain in the impingement position though he does have 10 to 15 degrees of internal rotation and full forward flexion.”  The incision was well healed and there were no neurovascular deficits.  Orthopedic surgery note, from the same date as the NARSUM, indicated the CI had significantly improved hip symptoms since surgery and that the CI did not have many hip complaints (noting complaints were those associated with abdominal compartment syndrome to include flank pain, irritable bowel syndrome (IBS), low back, and endocrine issues).  Formal physical therapy (PT) range of motion (ROM) measurements earlier in August are charted below and were recorded in the PEB disability description (DA Form 199).  

At the VA Compensation and Pension (C&P) examination in November 2008, performed 3 months before separation (8 months after surgery), the CI reported worsened right hip pain following surgery, required narcotic pain medication (Vicodin) and was using a cane to walk secondary to weakness on his right hip.  Physical examination showed the CI using a cane with a slightly antalgic gait to the right side secondary to unstable gait.  The hip surgical scars were well healed and non-tender.  Strength on the right leg was 4/5 (versus 5/5 on the left) and right hip pain-limited ROMs.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous 5099-5003 code (arthritis, degenerative), citing loss of joint motion.  The VA also assigned a 10% rating using the 5019 code (bursitis) based on the VA C&P examination 3 months before separation, citing painful/limited motion.  

There was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB based on all examinations in evidence.  The limitation of thigh extension documented in the PT examination (limited to 5 degrees) would support an alternative 10% rating under the diagnostic code for limitation of extension (5251), or the inability to cross legs would support an alternate 10% rating under thigh impairment (5253).  However, neither coding would provide for a higher rating than awarded by the PEB.  Additionally, the CI’s thigh extension and adduction had both improved by the pre-separation VA examination.  

The Board majority adjudged that there was not sufficient pathology to consider rating analogously for fracture, non-union, or malunion of the femur under the code for hip impairment related to femur impairment (5255).  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right hip condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that abdominal pain and GERD (gastroesophageal reflux disease) were not unfitting.  The CI had abdominal compartment syndrome as a complication to his right hip surgery in March 2010 and underwent emergent abdominal surgery for decompression with a second surgery for closure.  Following surgical recovery he developed chronic abdominal pain, flank pain, and irritable bowel symptoms.  The abdominal pain (including scar) and GERD were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All abdominal conditions were reviewed and considered by the Board.  

At the MEB examination in August 2008, 5 months prior to separation (4 months after surgery), the CI reported complaints associated with his abdominal compartment syndrome to include abdominal pain, flank pain, irritable bowel syndrome (IBS-alternating bowel habits and gastrointestinal upset), and endocrine complaints as well as exacerbation of low back pain and radicular type symptomatology.  Examination showed moderate left upper abdomen tenderness without rebound and a well healed midline surgical scar.  Bowel sounds were normal and there was no organomegally or hernia.  Rectal examination was normal.  Colonoscopy and EGD [esophagogastroduodenoscopy] in July 2008 were benign without evidence of inflammatory bowel disease or malignancy.  

In October 2008, 4 months before separation, the CI had a disability evaluation for the Social Security Administration.  He complained of having an upset stomach, abdominal pain, symptoms of irritable bowel syndrome, heart burn, abdominal discomfort, and chronic diarrhea since his abdominal surgery.  Abdominal examination showed no distension, tenderness, masses, ascities, or hepatosplenomegaly [benign exam].  

At the C&P examination in November 2008, performed 3 months before separation (8 months after surgery), the CI reported muscular flank pain, disfiguring painful stomach and abdomen, with warm moist heat and ice packs giving some relief.  He had symptoms of IBS that stabilized after starting Bentyl, but he still reported occasional diarrhea 2-3 times a week.  Abdominal examination was soft with normal bowel sounds and slight right upper area tenderness without rebound.  The 11cm abdominal scar was tender.  

In November 2008, after the VA examination, the CI was hospitalized for a lower gastrointestinal bleed.  The CI had complaints of 1-2 episodes of painful bloating bowel movement weekly associated with cramps since his surgery.  He had an episode of bright red blood while having a bowel movement and was hospitalized via the emergency department.  Diagnostic imaging noted slightly diffuse thickening in the transverse colon which was stated as a “nonspecific pattern [which] can be seen with colitis, inflammatory bowel disease and even with bowel spasm.”  Colonoscopy was “without evidence of abnormality” but showed two ulcers in the ileum likely due to medication use.  The assessment was a likely benign rectal outlet source from a difficult bowel movement, with no strong evidence of an inflammatory bowel disease.  
Post-separation colonoscopy in September 2009, 7 month after separation, diagnosed ulcerative colitis and the CI was on medications.  The VA examination in December 2009, 10 month after separation, indicated worsening of gastrointestinal symptoms with the condition rated at 30% by the VA effective February 2009.  

The Board adjudged that the post-separation VA examination indicated post-separation worsening and was not indicative of the CI’s disability picture at the time of separation.  There was no performance-based evidence from the record that any abdominal condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the abdominal pain contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right hip condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  In the matter of the contended abdominal pain and GERD conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  The single voter for dissent recommended modification and did not elect to submit a minority opinion.  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 20140318, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160008333 (PD201401493)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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