RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01604
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080513

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Signal Support Systems Specialist, medically separated for “chronic pain bilateral hips due to stress fractures,” with a disability rating of 20%.

CI CONTENTION:  “Rating and military discharge due to pain.  Since private insurance was purchased and several different conditions have been diagnosed due to injury obtained in the Army.  Sacroiliitis, leg length discrepancy and lower back pain.”  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 based upon a 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 – 20080220	VA - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Bilateral Hips due to Stress Fractures	5099-5003	20%	Bilateral Hip Condition	5255	0%	STR	
RATING:  20%	RATING:  0%	

ANALYSIS SUMMARY:  

Bilateral Hip Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed first left, then right hip pain during basic training.  It was aggravated after he jumped from a truck.  Initial X-rays were normal and the CI was treated with duty restrictions and medications, but his symptoms persisted and stress fractures of the hips were found.  The left hip stress fracture was treated with surgery on 22 March 2007.  The CI underwent rehabilitation in physical therapy (PT), but he was not able to return to full duty and he was entered into the MEB process.  The MEB forwarded bilateral femoral neck stress fractures for PEB adjudication.  

Formal range of motion (ROM) testing was done in PT on 29 August 2007, almost 9 months prior to separation and 5 months after surgery.  It was then repeated 4 months prior to separation.  Both are charted below.  At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 6 September 2007, 8 months prior to separation, the CI reported that he never regained full function of the hips and had tingling and numbness with constant hip pain.  On examination he was noted to have reduced strength and a surgical scar.  The MEB NARSUM examination on 20 September 2007, 8 months prior to separation, documented complaints of constant deep seated bilateral hip pain.  He could not run and walking was limited to one block.  He was limited to sitting for 15–20 minutes without changing his position.  He could not climb stairs.  The examination was accomplished by an orthopedic surgeon.  The CI did not appear to be acutely or chronically ill.  Tenderness was present over the left hip.  The ROM was limited.  The CI met an informal PEB on 25 October 2007 and a 10% rating for bilateral hip pain was recommended.  The CI non-concurred and requested a formal PEB.  This was delayed at the request of the CI in order for him to care for his wife who had a high risk pregnancy.  In orthopedics on 5 November 2007, the CI reported no change in his pain even though he had been removed from training and was at rest.  On examination, there was no swelling but diffuse tenderness was present and motion was limited.  The hips were stable and did not show weakness.  The CI did “not appear uncomfortable.”  The posture was normal, but the gait was not recorded.  On 4 February 2008, the CI had another orthopedic follow-up appointment.  He reported no change in his symptoms.  On examination he did “not appear uncomfortable.”  The hips were again tender and the ROM limited.  There was no swelling, instability, weakness, or muscle spasm.  Again, the posture was noted to be normal without comment on the gait.  

The CI did not report for the first scheduled VA Compensation and Pension (C&P) evaluation.  X-rays at the VA on 18 September 2008 showed pins in the left hip, but the hips were otherwise unremarkable without evidence of residual stress fractures.  In primary care on 11 September 2008, the CI reported that the right hip (which was normal on X-ray) was more painful than the left and that the pain was “reasonably well controlled” with Vicodin (a narcotic).  On examination, he was noted to be in no acute distress.  Hip flexion was reduced, but rotation was “good” bilaterally.  The CI was seen in primary care on 22 October 2008, 5 months after separation, and reported hip pain with prolonged sitting or walking.  It was improved with a hot bath.  An examination was not accomplished.  On 13 April 2009, 11 months after separation, the CI underwent a general VA C&P evaluation and reported ongoing pain and that he could not walk when his pain flared.  On examination, he was noted to have a slow, short stride and to walk with a cane very carefully.  However, he was also noted to walk without apparent pain.  A spine VA C&P examination was accomplished on 9 September 2009, 16 months after separation.  It noted that his pain was progressively worsening and that he could not walk more than a few yards.  He used a cane for assistance.  For the past 4 months, he had been working 12 hours a week as a salesman at Sears and reported no time lost from work.  However, he had a chair at the cash register to use if he needed to sit.  On examination, the gait was painful.  The motor examination of the hips was reduced at 4/5 for flexion and extension.  The examination for the knee, calf, and ankles showed normal strength.  Muscle tone was normal and atrophy was absent.  

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

Bilateral Hip (Thigh) ROM(Degrees)	PT ~9 Mo. Pre-Sep	MEB/PT ~4 Mo. Pre-Sep	C&P ~11 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (125 Normal)	112/112/112	110/110/110	120/120/120	103/103/103	120	95	
Extension (20)	-8/-8/-8	0/0/0	0/0/0	0/0/0	0/0/0	0/0/0	
External Rotation (45)							
Abduction (0-45)	20/20/20	20/20//20	40/40/40	20/20/20	30	45	
Adduction (45)							
Comment	No ratable limitation in crossing legs, out toeing.  ROM limited by pain.  	No ratable limitation in crossing legs, out toeing.  Mechanical limitation in ROM.	No ratable limitation in crossing legs, out toeing.  Pain with motion.	
§4.71a Rating	10% Bil Hips	10% Bil Hips	10% Bil Hips	

The Board directed attention to its rating recommendation based on the above evidence.  The Formal PEB rated the chronic pain and limitation of motion of the bilateral hips condition 20%, coded 5099-5003 (analogous to degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy.  The PEB also cited the VASRD for rating the hips at 10% each.  The Board noted that the bilateral factor should have been applied in this case, but was not.  However, this did not affect the rating adjudicated by the PEB.  The VA initially rated the bilateral hip condition at 0%, coded 5255 (impairment of the femur), noting that the CI did not show for the initial evaluation.  Subsequently, the VA rated each hip at 20%, based on the VA C&P examination 11 months after separation, citing the altered gait on examination.  The Board considered the evidence.  X-rays over one year after the surgery showed a normal right hip and a well healed left hip.  The CI demonstrated an abnormal gait, but it was specifically noted on the VA examination that it did not appear to be painful.  Atrophy was not documented on any examination and specifically excluded on one.  The medical officer opined that this would be expected with the limitation in function reported by the CI.  Although the right hip had shown a stress fracture (the basis for this is not found in the evidence available for review), subsequent X-rays were normal.  A compensable rating is not supported under any of the applicable codes for the hip or under the code 5003.  The left hip had surgery and post-surgical changes were evident on X-rays, although well healed.  This does not support a rating under 5003, but does support the use of the code 5255 (a 10% rating for a slight disability or 20% for a moderate disability).  The evidence does not support a finding of a severe disability to rate the condition at 30%.  The Board found no route to a rating higher than the combined 20% adjudicated by the PEB for the bilateral hip condition (including the bilateral factor).  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 condition.  

BOARD FINDINGS:  In the matter of the chronic bilateral hip pain 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140303, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

SAMR-RB						

14 NOV 2016

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, AR20160016542 (PD201401604)

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