RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02666
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080801

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard PV1/E-1 (11B, Infantryman) medically separated for a stress fracture in his left femoral neck.  This condition could not be adequately rehabilitated to allow him to finish basic training.  He was issued a permanent L3 profile and referred to a Medical Evaluation Board (MEB).  The “left femoral neck stress fracture” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The informal PEB adjudicated “left femoral neck stress fracture…,” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Please consider 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:  

IPEB – Dated 20080710	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Femoral Neck Stress Fracture	5299-5255	10%	Left Femoral Neck Fracture	5252	20%	20081022	
Other x 0	Other x 3	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20090602 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY: 

Left Femoral Neck Stress Fracture Condition.  On 14 March 2008 the CI underwent surgical fixation (percutaneous screws) of a left femoral neck stress fracture he suffered during basic training.  On 14 May 2008 (2 months after surgery and 3 months prior to separation) the CI requested to be weaned off crutches because left hip pain was “only occasional” (and) mild.”  Examination showed normal hip motion and gait.  Squatting was also normal, but “slight pain” occurred when lunging with left leg forward.  Follow-up on 28 May 2008 noted normal left hip motion and a normal gait.  The MEB examiner on 13 June 2008 noted a normal gait and stance.  
The narrative summary (NARSUM) on 26 June 2008 (1 month prior to separation) reported left hip pain that was present more than 75% of the day, for which he occasionally took anti-inflammatory pain medication.  Physical exam showed mild tenderness over well-healed incision sites.  Range-of-motion (ROM) was “symmetrical to the right side” but painful external rotation was present.  On 29 July 2008 (3 days prior to separation) the CI was evaluated in the emergency room after experiencing increased left hip and low back pain from tripping.  The CI was observed to move all extremities “well” and to display “nml (normal) ROM” of all extremities.  Left hip pain was present with internal rotation and x-rays showed no acute abnormalities or shifting of surgical hardware.  On 6 August 2008 (5 days after separation) the CI presented for VA care in an emergency room requesting medication for chronic hip pain, but without acute complaints.  Examination showed “nl (normal) L hip.”  Passive ROM caused “minimal pain.”

At the VA Compensation and Pension (C&P) exam performed three months after separation, the CI reported daily pain that lasted for hours.  Flare-ups were caused by “cold damp weather.  Being really, really active.”  He was prevented from “getting up and down too much” in his construction job at which he sometimes worked 12 hours per day (averaged 8 hours per day).  He could not ride bikes or motorcycles “for long rides.”  Examination showed a normal gait.  There were no observed functional limitations on standing or walking.

The goniometric 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.

Left Hip (Thigh) ROM
(Degrees)	MEB ~1 Mo. Pre-Sep	VA C&P ~3 Mos. Post-Sep	
Flexion (125 Normal)	103	22	
Extension (20)	0	9	
External Rotation (45)	Able to toe-out > 15 degrees	90	
Abduction (0-45)	33	42	
Adduction (45)	Able to cross legs	12	
Comment	+Painful motion	+Painful motion	
§4.71a Rating	10% (PEB 10%)	20% (VA 20%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating coded analogously to 5255 (femur, impairment of) while the VA rated at 20% using the 5252 code (thigh, limitation of flexion of).  The Board agreed there was sufficient evidence of painful motion to warrant a 10% rating IAW VASRD §4.59.  Although a 10% rating could also be supported by the limited extension noted on the MEB exam, 0 degrees of extension is inconsistent with the normal gait reported by all examiners proximal to the time of separation.  Likewise, the 22 degrees of flexion noted on the VA exam (cited by the VA as the rationale for a 20% rating) was regarded by Board members as inconsistent with any other flexion measurements in evidence, the two emergency room evaluations near the time of separation, or the ability to ride a bike or motorcycle.  The limitation of abduction in evidence was insufficient to warrant the next higher 20% rating via the 5253 coding pathway (thigh, impairment of).  Under the PEB’s coding pathway, “moderate knee or hip disability” was not reflected in the evidence; therefore the next higher 20% rating was not justified on this basis.  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 pain 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the left femoral neck stress fracture 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.

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 20140421, 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 XXXXXXXXXX, AR20160003710 (PD201402666)

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