RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02246
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard, E3, Counterintelligence Agent, medically separated for “chronic left hip pain,” with a disability rating of 10%.  

CI CONTENTION:  The CI was given a higher rating for her condition by the VA.  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 - 20051129	VARD - 20060322	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Hip Pain	5099-5003	10%	Left Piriformis Syndrome, Coxa Saltans, Left Quadriceps Tear with Left Hip Limitation of Motion and Sciatic Neuropathy	5299-5254	80%	20060126	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:    

Chronic Left Hip Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left hip condition began after a ruck march during basic training in April 2004 (21 months prior to separation) with a subsequent re-injury during exercise in September 2004.  Radiographic evaluation (plain X-rays) in September 2004 documented no evidence of trauma, arthritis, or inflammation.  Further imaging (magnetic resonance) in October 2004 documented a (quadriceps femoris) muscle strain that was “nearly resolved” in December 2004.  Radiographic evaluation (CT scan) of the lumbar spine in May 2005 and electrodiagnostic studies in July 2005 documented no evidence of bony pathology, disc herniation, or radiculopathy.  There was no indication for surgery.  Despite treatment, the hip condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and an MEB referral was made.  The MEB forwarded “left hip pain” for PEB adjudication.  The MEB NARSUM exam was performed on 6 April 2005 (9 months prior to separation).  The CI reported constant 8-10/10 pain radiating to the left calf with associated paresthesias and having difficulty dressing her lower body.  Physical exam showed a “markedly” antalgic gait, and tenderness of the left hip and gluteal muscles (piriformis).  Range of motion (ROM) measurements demonstrated slight decrease in motion however, these measurements were recorded as passive ROM of the left hip.  The examiner reported the CI was requested to actively move the leg and did not, yet muscle contraction and relaxation were still noted when the CI was distracted.  

At the VA Compensation and Pension (C&P) exam on 3 May 2005, (8 months prior to separation), the CI reported constant pain, with inability to lie on her left side, sit for more than 30 minutes, walk for more than 10 minutes and drive long distances.  Physical exam showed initial flexion to 33 degrees that was limited to 23 degrees after repetition (normal 125).  Initial external rotation was 26 degrees and limited to 18 degrees after repetition (normal 45).  Abduction improved to 15 degrees after repetition (normal 45).  At the MEB exam (recorded on DD Form 2807 and 2808) dated June 2005 (7 months prior to separation), the CI reported “inability to lift the leg or control flexion.”  Physical exam showed “decreased” ROM and strength (3/5), with no evidence of atrophy or edema.  

At the VA C&P exam in January 2006, (3 days after separation), the CI reported constant 6/10 pain.  Physical exam showed ambulation with a cane and an upright posture.  There was tenderness of the left buttock and thigh muscle, moderate weakness with increased sensitivity to touch.  There was inability to lift the leg off of the exam table; however, with assistance, hip flexion was to 90 degrees (normal 125).  There was normal extension, external rotation to 17 degrees, and decreased abduction and adduction (22 and 12 degrees respectively; normal 45 each).   

At a VA primary care visit in February 2006 (2 weeks after separation), the CI reported having hip pain and frequent falls.  She reported falling on the way to the appointment and was “wheelchair bound” at the exam.  An orthopedic evaluation, on the same day, reaffirmed the diagnoses of “snapping hip syndrome” (external coxa saltans), with iliotibial band and piriformis syndromes.  The examiner recorded muscle tone was normal in the CI’s lower extremities even though she was completely unable to weight bear on both of her legs when asked to transfer onto and off a table in the examination room.  In review of her diagnostic imaging and neurologic testing results, the examiner could not reconcile the CI’s clinical presentation with the normal results from these tests.  At a physical therapy clinic examination on 23 February 2006, a month after separation, the CI was able to flex, abduct and adduct her bilateral hips, showing 5/5 muscle strength, as well as perform a full squat without difficulty.   At a VA C&P exam in October 2006, (8 months after separation), the CI reported use of a cane; moderate pain while walking and after prolonged sitting; and having fallen on wet surfaces about 5 times in the last month.  Physical exam showed no painful motion initially, however, there was “pain following repetitive use.”  There was tenderness of the proximal thigh (quadriceps muscle), and an antalgic gait.  Flexion was to 108 degrees and external rotation was to 12 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous code 5099-5003 (degenerative arthritis), referencing the USAPDA pain policy and citing painful motion.  The VA initially assigned a 30% rating using code 5252 (thigh, limitation of flexion) based on the VA C&P exam 8 months prior to separation.  After an acute fall on the way to a VA appointment the rating was revised to 80% rating using code 5299-5254 (analogous to flail joint of the hip) and citing evidence “severe functional impairment.”  Due to the significant differences between the ratings adjudicated by the PEB and VA proximate to separation, the Board carefully considered the record in its entirety in order to develop a consistent picture of the CI’s left hip condition.  

The Board first considered the evidence for a higher than 10% rating.  There was no documentation of hip ankylosis (5250; with the hip in flexion at an angle between 20 and 40 degrees…), no accurate measurement proximate to separation of limitation of flexion (5252) to 30 degrees or less, and no limitation of abduction (5253) beyond 10 degrees in support of a higher rating.  There was no documentation of femur fracture, nonunion, or malunion with moderate or marked hip disability (5255) for a higher rating.  There was no evidence of loss of joint function caused by instability that would result in a flail joint (5254), and therefore a rating using that code was not reflective of the CI’s disability.  

The Board noted that several exams leading up to and including the MEB/ NARSUM and Orthopedic exams in April 2005 supported a 10% rating based on painful and limited motion.  A VA exam in October 2006 (8 months after separation) also supported a 10% rating.  Members agreed that the CI’s refusal to attempt hip flexion (as reported by the NARSUM examiner) does not satisfy the requirement under VASRD §4.46 (accurate measurement) for criteria in support of a compensable rating.  It was also noted that the VA C&P exams from January and February 2006 had occurred after several falls reported by the CI and would explain the functional impairment evident at the time.  Board members agreed that the reported falls clearly resulted in the significant, but temporary, impairments documented; and, therefore, did not accurately depict the chronic disability at the time of separation.  As there was consistent evidence both before and after separation favoring a 10% rating based on painful motion and the limitations recorded, the Board concluded that reasonable doubt did not favor the CI for a higher rating in this regard and therefore recommended the 10% 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:  In the matter of the left hip 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 20140520, 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 XXXXXXXXXXXXXXXXXXXX, AR20160007486 (PD201402246)

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