RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01917
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Food Service Specialist, medically separated for “chronic pain right hip and both ankles due to stress fracture,” with a disability rating of 0%.

CI CONTENTION:  “Please consider all conditions.”  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 - 20011214	VARD -  20020816  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Right Hip and Both Ankles …	5099-5003	0%	Right Proximal One-Third Femur Stress Fracture	5255	10%	20020816	
			Residual of Left Ankle Strain	5271	0%	20020816	
			Residual of Right Ankle Strain	5271	0%	20020816	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Pain Right Hip.  The PEB combined the right femur stress fracture and right and left ankle pain conditions as a single unfitting condition characterized as pain right hip and both ankles due to stress fractures,” coded 5099-5003 and rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right hip condition and the bilateral ankle conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated, including consideration of separate rating of the right and left ankles.  

The permanent profile dated 3 December 2001 listed “multiple joint complaints.”  The commander’s statement implicated the “stress fractures of his right hip and bilateral ankles” as impairing the CI’s duty performance.  Notes in the service treatment record indicated treatment visits for right hip pain and bilateral ankle pain, but at serial visits the CI also reported pain in the bilateral ankles and knees, legs, and back.  A Bone scan (original report not in record) was noted by the orthopedic specialist to show increased uptake in the upper right femur and bilateral feet, but the ankles were not visualized.  A temporary profile dated 22 October 2001 listed “bilateral LE pain” and indicated “may use crutches.”  The MEB forwarded “bilateral ankle pain” to the PEB.  

The Board first considered if the right hip condition and the bilateral ankle condition having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The bilateral “LE pain” was temporarily profiled and subsumed in the permanent profile for “multiple joint complaints,” and the commander’s statement implicated both conditions.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that each of the bundled conditions was reasonably considered separately unfitting.  The Board then considered its rating recommendation for the unfitting conditions at the time of separation, beginning with the unfitting right hip condition followed by the unfitting bilateral ankle condition, with further consideration of separate fitness and rating recommendations for each ankle.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hip condition began in October 2001 during training.  A bone scan showed increased uptake in the right femur (hip).  At an orthopedic evaluation 6 November 2001, months before separation, physical examination showed full range of motion of the hip.  There was no pain with rolling the hip from side to side.  There was TTP over the groin area, but not the greater trochanter of the femur (bursitis).  The CI did not improve with conservative treatment including crutches.  The MEB forwarded “right proximal one-third stress fracture” for PEB adjudication.  The MEB examination (recorded on DD Forms 2807 and 2808) dated 21 November 2001, 2 months prior to separation, noted tenderness of the femoral neck and limited hip flexion due to pain.  The MEB NARSUM examination on 29 November 2001, 2 months prior to separation, noted complaints of hip pain without improvement with treatment that caused him to be unable to train.  The MEB NARSUM cited the same examination findings as noted at the 6 November orthopedic examination summarized above.  

At the VA Compensation and Pension (C&P) examination on 6 June 2002, 5 months after separation, the CI reported that the hip pain continued after separation.  The CI was using a cane.  The physical examination showed TTP of the right greater trochanter, but not of the hip joint itself.  The CI had limited symmetrical ROM of both hips.  There was painful ROM of the right hip and right hip pain with left hip motion.  Hip ROM was 60 degrees flexion (normal 125 degrees) extension of 5 degrees (normal 20 degrees), external rotation 50 degrees (normal 45 degrees).  Right hip X-rays noted minimal joint narrowing with no fractures.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the right hip and bilateral ankle conditions as noted above and rated 10%, coded 5099-5003 (analogous to degenerative arthritis, citing the USAPDA Pain Policy.  The original VARD did not service-connect the right hip condition, noting that there was no evidence of a chronic issue at the time and it was reasonable to assume that once the CI was removed from the rigors of basic training he would improve.  The later VARD dated 16 August 2002 service connected the right hip stress fracture and rated it 10%, coded 5255 (femur impairment) for malunion of the femur with mild hip disability, based on the C&P examination 5 months after separation.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of thigh flexion or thigh impairment (5252, 5253).  However, there was evidence of limited thigh extension at the C&P examination and painful motion with functional loss both at the orthopedic examination cited by the MEB NARSUM and the C&P exam, supporting a 10% rating (based on §4.59, §4.40 and §4.45) coded analogously to 5261.  There was no evidence of moderate hip or knee disability, a “false joint” at the site of the fx, or nonunion of the femur fx to support higher rating.  The examinations proximate to separation did not demonstrate the presence of hip ankyloses, flail hip joint, (5250,5254) for a rating under the respective codes.  There was therefore no route to a rating higher than 10% under any applicable VASRD §4.71a code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right hip condition, coded 5299-5251.  

Chronic Pain Both Ankles due to Stress Fractures.  According to STR and the MEB NARSUM, the CI’s bilateral ankle condition began in October 2001, without specific trauma.  The CI reported right greater than left ankle pain, with swelling that caused him to limp.  A bone scan 9 October 2001 noted increased diffuse uptake in the feet, but did “not visualize ankles.” An orthopedic examination on 19 October 2001 noted full ROM of the ankles without swelling or instability.  There was TTP over the medial and lateral malleoli.  The CI did not improve despite crutches.  The MEB forwarded “bilateral ankle pain” for PEB adjudication.  The MEB examination noted the CI had an antalgic gait and was using crutches.  There was TTP of the distal tibias.  The MEB NARSUM noted complaints of right greater than left ankle pain that caused the CI to be unable to train.  The MEB NARSUM cited the same examination findings as noted at the 19 October Ortho examination summarized above.  

At the VA Compensation and Pension (C&P) examination on 6 June 2002, 5 months after separation, the CI reported bilateral ankle pains that were less severe than his right hip pain.  The CI reported he had been taking daily pain medication, primarily because of his hip pain and was using a cane because of the hip.  The physical examination was reported for the bilateral ankles and noted no swelling, deformity or effusions.  There was TTP present only on the lateral malleolus of the right ankle.  Ankle ROM was described as “full”, and was bilaterally symmetrical with dorsiflexion of 12 degrees (normal 20) and plantar flexion of 40 degrees (normal 45).  Bilateral ankle X-rays were read as negative.  

As noted above a temporary profile noted bilateral LE pain and indicated “may use crutches” and the permanent profile listed “multiple joint complaints.”  The commander’s statement implicated the “stress fractures of his right hip and bilateral ankles” as impairing the CI’s duty performance.  Notes in the service treatment record indicated treatment visits for bilateral ankle pain.  A temporary profile dated 22 October 2001 listed bilateral “LE pain” and indicated “may use crutches.”  The MEB forwarded “bilateral ankle pain” to the PEB.  

The Board agreed above that the bilateral ankle condition was reasonably considered separately unfit when considered apart from the hip condition. The Board next considered if the right ankle and left conditions remained separately unfitting when considered individually as established above.  In this case, both ankle joints, were considered to fail retention standards, both were implicated by the NARSUM and in the commander’s statement, and both conditions were subsumed in the temporary bilateral LE pain profile and the permanent profile.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that each of the bundled ankle conditions was reasonably considered unfitting and each condition was therefore eligible for separate Service ratings.  

At the orthopedic examination cited by the MEB NARSUM there was full ankle ROM.  At the C&P examination although ankle dorsiflexion was 12 degrees bilaterally, the orthopedic specialist described the ankle ROM as full and symmetrical and neither examination noted the presence of painful joint motion of the right or left ankle.  The CI was noted to be using crutches on the profile for the bilateral LE pain, which also would have benefitted pain from the right hip condition.  This was consistent with the report at the C&P examination by the CI that hip pain was the major issue and he was at that time using a cane due to the hip pain.  The Board judged that the evidence did not provide support for “moderate” limitation of motion of the ankle joint to support a rating under diagnostic code 5271 (limitation of motion).  There was no objective abnormality of the ankles demonstrated on imaging and the only abnormalities noted on clinical examination were tenderness of the bilateral ankles at the MEB NARSUM examination and tenderness of the outer aspect of the right ankle only at the C&P examination.  At the MEB NARSUM examination the CI reported right greater than left ankle pain and the C&P examination noted only localized TTP of the right ankle.  The Board concurred that a 10% rating for functional loss (§4.40, §4.45, §4.59) due to pain was appropriate for the right ankle condition, but not supported for the left ankle at separation.  The bilateral ankle pain diagnosis due to presumed stress fractures or due to stress reactions of the feet supported a single 10% coded 5099-5022 (analogous to periostitis).  Since code 5022 (5013 through 5024) defaults to 5003 (degenerative arthritis) rating criteria, without regard to radiographic findings, a 10% rating for two major joints is supported.  Members agreed, therefore, that the evidence did not support recommending separate right and left ankle disability ratings.  The Board considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the bilateral ankle condition, coded 5099-5022.  

BOARD FINDINGS:  In the matter of the “right proximal one-third femur stress fracture” condition, the Board unanimously or majority recommends a disability rating of 10%, coded 5299-5261 IAW VASRD §4.71a.  In the matter of the bilateral ankle pain condition, the Board unanimously or majority recommends a disability rating of 10%, coded 5099-5022 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Right Proximal One-third Stress Fracture	5299-5261	10%	
Bilateral Ankle Pain	5099-5022	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140429, 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 XXXXXXXXXXXXXXXXXX AR20160014868 (PD201401917)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA