RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02736
BRANCH OF SERVICE:  Army	BOARD DATE:  20150401
SEPARATION DATE:  20090108

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-3 (Basic Trainee) medically separated for a left hip condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Left hip pain and low back pain (LBP), both characterized as medically unacceptable, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated chronic left hip pain as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  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:

Service IPEB – Dated 20081217	VA* - (18 Days Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Hip Pain…	5009-5003	10%	Left Hip Strain	5253	10%	20090126	
Low Back Pain	Not Unfitting	No VA Placement	
Other x 0 (Not in Scope)	Other x 0	
Combined:  10%	Combined:  10%	
*Derived from VA Rating Decision (VARD) dated 20090515 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Chronic Left Hip Pain.  During basic training in September 2008, the CI stepped into a hole while running and developed left hip pain that continued throughout the rest of his service career.  He was hospitalized for 2 days; a complete radiologic work-up did not reveal any musculoskeletal abnormalities.  His treatment consisted of pain medications, physical therapy, and restricted activities.  His discharge diagnosis was left hip strain.

At the narrative summary on 20 November 2008, approximately 6 weeks prior to separation, the CI endorsed constant left hip pain without symptom extension into the lower extremity.  His recorded hip and low back range-of-motion (ROM) was noted as “full” with associated painful motion to the left hip.  His pain was categorized as “slight” and “frequent.”  Hip tenderness was present.  His permanent profile listed left hip pain and back pain as the diagnoses and the commander’s letter endorsed only the hip condition.

At the VA Compensation and Pension general medical examination performed on 26 January 2009, approximately 3 weeks after separation, the CI endorsed stiffness, pain, and instability about the left hip.  He denied weakness, incoordination, episodic locking, or painful “flare-ups” of the left hip.  Specifically, it was noted that “no” was documented in regards to the condition affecting motion of the hip.  The record further noted “no limitations on standing” and the ability to walk a quarter mile.  The physical examination revealed the use of a cane for ambulation, antalgic gait, and guarding of left hip movement.  There was limited and painful motion of the left hip.

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)	NARSUM ~2 Mo. Pre-Sep
(20081120)	PT ~6 weeks Pre-Sep
(20081210)	VA C&P ~ 3 weeks Post-Sep
(20090126)	
Flexion (125 Normal)	‘Full’	(120)	90	
Extension (20)	“	(10)	30	
External Rotation (45)	“	--	--	
Abduction (0-45)	“	(30)	15	
Adduction (45)	“	Unable to cross legs = “No”	--	
Comment	Painful motion; antalgic gait; tenderness	Painful motion	Use of cane; painful motion; guarding; ‘unable to cross left leg over right leg’	
§4.71a Rating	10%	10% (PEB 10%)	10% (VA 10%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA chose different coding options for the hip condition, although both arrived at the same 10% rating.  The PEB coded analogous to degenerative arthritis and the VA cited limited adduction as referenced with the inability to cross legs.  The PEB’s 10% rating rested on VASRD §4.59 (painful motion) as well as §4.10 (functional impairment), §4.40 (functional loss), and §4.45 (Joints) as listed on DA Form 199.  Board members concluded that absent hip fracture without nonunion or malunion and or the presence of hip disability greater than “slight,” there was no route to an impairment rating higher than 10% under applicable VASRD codes and no coexistent pathology was present which would merit additional rating for the hip condition under any other code.  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.

Contended PEB Conditions.

Low Back Pain.  The service treatment record contained a paucity of record documents specifically addressing a low back condition.  Radiologic tests revealed lumbosacral disc bulging without nerve compression.  Physical therapy documented ROM measurements on 10 December 2008, approximately a month prior to separation, revealed limited motion and the ‘appearance’ of painful motion.  Specifically, the examiner noted the following:

“Limitation appears to be subjective pain related.  However, the [CI] had more movement, when not directly observed.  [He] had >90 degrees lumbar flexion when standing and taking off shoes.  [He] demonstrated good lumbar/hip extension, without obvious pain distress when doing standing quad stretch.  [He] demonstrated near normal lumbar side bend when doing standing side stretches before the "exam" began.”

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.

Thoracolumbar ROM
(Degrees)	NARSUM ~2 Mo. Pre-Sep
(20081120) 	PT ~6 weeks Pre-Sep
(20081210) 	VA C&P ~3 weeks Post-Sep
(20090126) 	
Flexion (90 Normal)	‘Full’	(65)	90	
Extension (30)	“	(35)	25	
R Lat Flexion (30)	“	(25) 	25	
L Lat Flexion (30)	“	(20) 	25	
R Rotation (30)	“	(20) 	25	
L Rotation (30)	“	(15) 	25	
Combined (240)	“	180	215	
Comment	Painful motion; antalgic gait; tenderness 	See comments above	No abnormalities of spinal muscle, guarding, tenderness; painful motion not cited	
§4.71a Rating	10%	10%	0% (No VA claim)	

The Board’s main charge is to assess the fairness of the PEB’s determination that the low back condition was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Although the low back condition was listed on the permanent profile, it was not implicated in the commander’s statement nor judged to fail retention standards.  Board members acknowledged and placed high probative value on the physical therapist’s additional comments of near normal limits of motion when not under direct observation in determining the CI’s total functional abilities.  The back condition was reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that the LBP significantly and separately interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended back condition and no additional disability rating is recommended.

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 hip condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended low back condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization 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, AR20150014876 (PD201402736)

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						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA