RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01936
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Band Member, medically separated for “painful scar right abdomen and hip following surgery for cystic hygroma,” with a disability rating of 10%.

CI CONTENTION:  “Continues to cause problems and Dr. specializing in pain management suggested I try for a reevaluation”   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 - 20070828	VARD - 20080328	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Painful Scar Right Abdomen And Hip Following Surgery For Cystic Hygroma	7899-7804	10%	Depression and Painful Scar with Keloid Formation and Pain on Motion, Right Hip S/P Surgical Removal of Cystic Growth	7801-7804	10%	20071212	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Painful Scar Right Abdomen and Hip.  The service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM) indicated that in June 2006 the CI complained of a lump on her right hip (upper thigh/lateral buttock) that was present since September 2005 and caused occasional discomfort.  From a historical basis the CI had a “bruise” removed in the right inguinal area as a 10-11-year-old.  Activity and clothing aggravated the right hip mass, which was tender to palpation and was 2-3 cm in size.  Needle aspiration revealed approximately 7 ml of yellow fluid on 18 January 2006.  An MRI of the pelvis in March 2006 demonstrated a complex serpiginous cystic lesion involving the subcutaneous fat overlying the right gluteal muscles from the anterior/superior iliac spine to the buttock region.  Hip pain was treated Daypro (oxaprozin, a nonsteroidal anti-inflammatory drug (NSAID)).  A compression garment was considered for treatment; measurements were taken; and the garment was ordered in May 2006.  The CI underwent surgery in December 2006 and had a postoperative infection that was treated with antibiotics and packing.  However, the compression shorts caused constant pressure and her hip “tires out when ascending stairs.”  Magnetic resonance imaging (MRI) in April 2007 showed scarring and cystic changes of the subcutaneous fat between 9 mm to 2 cm in size.  On 27 July 2007 the CI underwent successful foam sclerotherapy placement (to cause shrinkage or scarring) under duplex scan guidance into the cystic hygroma.  One month later the injection site showed no abnormalities.  There was no induration, erythema, drainage or tenderness to palpation and the CI had not noted any new symptoms or problems.    

The NARSUM noted several scars of the abdomen and right hip.  Drainage scars were painful at palpation with a small bump right underneath that was consistent with the return of her lesion which was painful at palpation.  The ROM of the right hip is in the chart below.  Right hip strength was slightly decreased and the Thomas (to check for hip flexion contractures), Faber (to determine pathology of the hip joint), and Trendelenburg (to identify weakness of the gluteus medius muscle) tests were positive.  The CI reported pain when sitting for a couple of hours, standing for an hour, walking depending on pace, bending, climbing, and lifting.

At the MEB examination, the CI reported on DD Form 2807-1 dated 27 February 2007 having had a cystic hygroma and its removal.  The examiner noted an umbilical and two right anterior hip scars as well as a mild leg length discrepancy, right greater than left by ½ inch on DD Form 2808 dated 15 March 2007.  The commander’s statement dated 21 May 2007 indicated the CI was physically incapable of reasonably performing her duties including marching as a member of the band due to her chronic hip problems.  A permanent L3 profile was issued on 21 June 2007 for right hip pain with limitations of no 2-mile run or sit-ups and all functional military activities except wearing a protective mask and all chemical defense equipment.

At the VA Compensation and Pension (C&P) examination dated 12 December 2007, performed 2 months after separation, the CI reported pain of 5/10 (10 being the worst pain) was still present in the area where the mass of the right hip was excised and the pain increased when she walked for more than a mile or stood for more than ½ hour; however, she denied use of any assistive aids.  On examination she had a very, very mild limp on the right and her posture was erect.  There was a 9.0 x 0.4 cm scar on the right hip, which was depressed 0.3 cm with some puckering in the middle and some fixation along 1 cm of the scar in the lower half.  There was keloid formation on the entire scar, more pronounced with light pigmentation on the superior part of the scar.  There was no tenderness on manipulation of the scar.  However, on pressure of the scar, she complained of right hip pain.  On palpation, no definite recurrent cystic structure was noted below the scar. Zero percent of the exposed body surface and zero percent total body surface was affected.  The right hip showed no deformity and there was no palpable mass just below the scar, but there was tenderness on palpation of the joint line and no crepitus on motion.  ROM measurements are in the chart below.  There was no muscle loss of either thigh or leg; shortening of the right lower extremity was noted to be ¼ inch compared to the left. 

The range of motion (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.

Right Hip (Thigh) ROM
(Degrees)	PT ~6 Mo. Pre-Sep
	MEB ~4 Mo. Pre-Sep
	VA C&P ~2 Mo. Post-Sep
	
Flexion (125 Normal)	115 115 110 (113)	113	115	
Extension (20)	16 16 16 (16)	16	20	
External Rotation (45)	-	-	60	
Abduction (0-45)	45 45 50 (47)	47	45	
Adduction (45)	-	18	20	
Comment	Pain not a significant factor	Motor strength slightly decreased	Painful motion	
§4.71a Rating	0%	0% (PEB 10% for scar)	0% (VA 10% for scar)	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 7899-7804 for a painful scar of the right abdomen and hip
following surgery for a cystic hygroma.  The VA assigned a 10% rating using code 7801-7804 for a depressed and painful scar with keloid formation and pain on motion, right hip status post- surgical removal of cystic growth.  The record indicated the CI had several scars; however, there is a disparity among the examinations as to how many scars were actually present.  The NARSUM examination noted several scars; the MEB examiner noted three scars, one of which was on the abdomen that was from childhood; and the VA examiner described one scar.  Therefore, since the MEB examination was proximate to separation, two scars were related to the cystic hygroma removal when the CI was on active duty.  Code 7804 Note (2) indicates “If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars.  While the MEB examiner did not comment whether the scars were unstable or painful, the NARSUM examiner did note painful scars and the VA examiner recorded pressure on the scar evoked right hip pain.  Therefore, Board members discussed whether an additional 10% rating is warranted based on code 7804 Note (2).  Board members agreed that there were at least two scars that were painful by taking into account the drainage scars as well as the operative scars.  A higher rating based solely on the number of scars requires three or four scars that are unstable or painful, which was not in evidence in the service treatment record.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the painful scar condition.  

BOARD FINDINGS:  In the matter of the painful scar condition, the Board unanimously recommends a disability rating of 20%, coded 7899-7804 IAW VASRD §4.118.  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 her prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Painful Scar Right Abdomen and Hip	7899-7804	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131230, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX, AR20160010875 (PD201401936)

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