RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01852
BRANCH OF SERVICE:  Army	BOARD DATE:  20150326
SEPARATION DATE:  20070711

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-5 (Civil Affairs Specialist) medically separated for chronic left-hip pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty, or satisfy physical fitness standards.  She was issued a temporary L2 profile and referred for a Medical Evaluation Board (MEB).  The chronic left-hip pain condition, characterized as “chronic left-hip pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic left-hip pain” as unfitting, rated 10% citing the US Army Physical Disability Agency (USAPDA) pain policy.  The CI appealed to the Formal PEB (FPEB) which rated the hip condition at 20% citing the USAPDA pain policy.  The CI was medically separated.

CI CONTENTION:  “Please review all conditions”

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:

Service FPEB – Dated 20070530	VA* - (~17 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left-Hip Pain	5099-5003	20%	Left Hip Strain	5255	20%	20081208	
Other x 0 (Not in Scope)	Other x 1	
RATING:  20%	RATING:  80%	
*Derived from VA Rating Decision (VARD) dated 20090205 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Left-Hip Pain Condition.  The narrative summary (NARSUM) and treatment records indicated onset of left hip pain during a ruck march at the end of basic training.  Hip pain recurred at her next duty station with bone scan indications suggestive of stress at muscle insertions of both hips (femur) without frank stress fractures.  Symptoms abated with profile restrictions, medication and physical therapy (PT).  While deployed to the Horn of Africa, the CI had severe left hip pain during a 5-K run and was medically evacuated in January 2007.  X-rays and magnetic resonance imaging (MRI) scans were essentially normal with no evidence of arthritis, bony abnormality or stress fracture.  Pain was 5-6/10 on awakening and exacerbated up to 8-9/10 by prolonged walking, standing and sitting.  The CI was on pain medications (anti-inflammatory, narcotic and muscle relaxant) and used a cane with severe pain episodes.  The NARSUM exam noted a normal appearing hip with tenderness on the left mid groin and painful motion without limitation of range-of-motion (ROM).  Formal active ROMs for the MEB (performed by PT) are charted below.  An April 2007 treatment note (for low back pain [LBP], 3 months prior to separation) had indicated an abnormal gait with flexed hips, use of a cane and decreased strength of bilateral hip flexion at 4+/5.  There was decreased touch (tactile stimulation) “to the leg/foot to entire left lower extremity most prominent along lateral aspect.”  Left knee and ankle reflexes were normal.

After separation treatment notes for LBP and left hip pain documented a normal electrodiagnostic consultation (with EMG/NCV) in October 2008 (15 months after separation) which included an exam with normal hip strength (5/5), normal ROM, and normal sensory and reflex exams of the lower extremities.  EMG/NCV was normal.

At the VA Compensation and Pension exam performed 17 months after separation, the CI reported similar history of pain onset with symptoms of left hip pain, instability stiffness and weakness.  The CI denied effusions (swelling) or locking up. The CI related inability to stand for more than a few minutes, walk over 1/4 mile, and had occasional use of a cane with difficulty dressing and shopping.  Exam noted evidence of abnormal weight bearing from asymmetric foot callus formation.  There was tenderness and apparent pain at rest.  ROM was painful and is summarized below.  There was no ROM change following repetition.  X-ray showed no fracture or degenerative processes of the left hip.  MRI documented an unremarkable hip joint with essentially normal pelvis.

The goniometric 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)	PT ~4 Mo. Pre-Sep	VA C&P ~17 Mo. Post-Sep	
Flexion (125 Normal)	123, 123, 124	45	
Extension (20)	14, 13, 14	15	
Abduction (0-45)	42, 43, 42	20	
Comment	Painful ROM; tender
Toe-out > 15
Able to cross legs	Painful ROM; tender
Toe-out< 15
Not able to cross legs	
§4.71a Rating	10% (PEB 20%)	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB 20% rating was based on the USAPDA pain policy.  The remote VA exam indicated significantly greater ROM limitations that were rated at 20% for moderate hip disability under code 5255 (femur, impairment).  The service exams did not warrant any rating higher than 20% and VASRD-only rating of those exams would likely be less than 20%, as even if incapacitation were conceded, there was only one major joint involved (under joint diagnostic codes 5013 through 5024 and code 5003).  The Board adjudged that the significantly worsened ROMs noted 17 months after separation were not indicative of the CI’s condition at separation.  Although the PEB rating used the pain policy, the coding was analogous, applicable to the hip joint, and there was no better VASRD coding for rating at the time of separation.  By law, the PDBR may not lower the service disability rating.

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.  As discussed above, FPEB reliance on the USAPDA pain policy for rating the hip condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the left hip condition, 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 20140430, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150013657 (PD201401852)

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:

Encl						     XXXXXXXXXXXXXXX										     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA