RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02802
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Combat Medic, medically separated for “chronic left hip pain,” with a disability rating of 10%.   

CI CONTENTION:  “Please consider all conditions.”	

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 - 20090219	VARD - 20091215	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Hip Pain	5099-5003	10%	Left Hip Condition	5299-5252	NSC	STR	
Chronic Right Hip Pain	Not Unfitting	Right Hip Condition	5299-5252	NSC		
Adjustment Disorder, Resolved	Not Unfitting	Adjustment Disorder with Depression and Anxiety	9440	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:   

Chronic Left Hip Pain Condition.  The service treatment record indicated a bone scan report dated 25 September 2007 of the pelvis performed for right hip, knee, and ankle pain in week 7 of basic training demonstrated a focal hot uptake at the left SPR (superior pubic ramus) at the acetabulum (the socket of the hip joint) consistent with a stress fracture.  No right hip or pelvic lesions were seen.  Overuse uptake was noted at both medial knees.  There was decreased uptake consistent with disuse of the right leg consistent with the history of pain.  The CI was treated with crutches and was on profile for 2 weeks.  Ibuprofen (a nonsteroidal anti-inflammatory drug) (NSAID) reportedly did not help the pain.  Imaging on 29 January 2008 revealed a left acetabular subchondral (below the cartilage) lucency favoring a cyst without other signs to suggest a recurrent left stress fracture.  Evaluation on 30 January 2008 noted left hip joint pain, worse while running and jumping.  Lateral thigh pain was worsened by ice and radiated down the leg and subsided when walking stopped.  The trochanteric bursa was tender on palpation as was the femoral triangle (inner, proximal thigh).  Physical therapy assessment revealed hip pain had been present for 4 months.  Examination revealed an unremarkable gait with and over pronation type foot motion.  The range of motion (ROM) measurements of the hips were 120 degrees flexion and 15 degrees extension.  Special hip tests were negative except 90/90 (straight leg raise test to determine hamstring tightness), which lacked 10 degrees bilaterally.  Tenderness was found over the greater trochanter only.  Arch supports were dispensed in May 2008.  An MRI of the left hip in October 2008 was normal.  Physical therapy was carried out between April and 31 July 2008, but at a visit dated 4 August 2008 the CI indicated the left hip pain started getting worse 1 week earlier.  An MRI and an X-ray series of the left hip in October 2008 were normal.  A note dated 30 October 2008 noted the ROM measurements of the left hip were 110 degrees flexion, 10 degrees extension, 50 degrees external rotation and 50 degrees internal rotation.  There was no evidence of a labral tear, stress fracture or femoroacetabular impingement on history/physical or imaging of the left hip and there was no surgical pathology. Due to continued pain the examination indicated the CI was not fit for duty.  

The Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 11 December 2008 noted the CI complained of chronic left hip pain that began during basic training one morning after performing a ruck march.  With crutches and NSAIDs for 2 weeks the pain was alleviated somewhat.  During his last ruck march for basic training, he developed pain in the middle of the march and at the end had to “drag his left leg.”   During AIT after a physical fitness test, he developed left hip pain again and was once more placed on crutches.  After a PCS [permanent change of station], he limped secondary to left hip pain and denied any significant improvement with physical therapy. At the time of the NARSUM the CI stated the left hip pain was sharp in quality with a severity of 5/10 (10 being the worst pain pain) with exacerbations to 8/10; and, he had daily flares for 1 to 2 hours after walking or prolonged standing.  

At the MEB examination 19 November 2008 the CI reported on DD Form 2807-1 his left hip swelled up and he had pain in both hips.  At the MEB physical examination dated 11 December 2008, the examiner noted on DD Form 2808 tenderness to palpation on the left anterior hip joint and greater trochanteric area and “hip pain with hip flexion, extension and abduction.”  The ROM measurements were flexion 108 degrees (wring unclear), extension 3 degrees, and abduction 31 degrees.  Strength was 4/5 with hip flexion due to pain.  A permanent L3 profile was issued in December 2008 with limitations of physical fitness testing and all military functional activities except wearing a protective mask and all chemical defense equipment.  Specifically, he was precluded from running, jumping or impact activities.  The commander’s statement dated 5 January 2009 indicated the CI performed light work calls and administrative duties.  He was unable to wear his OTV (outer tactical vest) and ACH (Army combat helmet), stand for long periods of time, or lift more than 48 pounds.  The physical restrictions hindered his ability to adequately perform the normal duties of his MOS.

The CI did not attend the VA Compensation and Pension (C&P) examination scheduled for 3 April 2009.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10 rating using code 5099-5003 (degenerative arthritis) for chronic left hip pain.  The VA assigned a NSC (not service connected) rating using code 5299-5252 (Thigh, limitation of flexion) since the CI did not have a VA C&P examination.   The Board did note that using code 5251 (Thigh, limitation of extension) also afforded a 10% rating for extension limited to 5 degrees, but it offers no additional benefit to the CI since pyramiding IAW VASRD §4.14 is to be avoided.  The Board then sought a route to a higher rating; however, in the absence of hip ankylosis, limitation of flexion of the thigh, impairment of the thigh, a flail joint of the hip, or impairment of the femur, the Board was unable to find a higher 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 chronic left hip pain condition.  

Contended PEB Conditions-Chronic Right Hip Pain and Adjustment Disorder, Resolved.  The Board’s main charge is to assess the fairness of the PEB’s determination that chronic right hip pain and adjustment disorder, resolved were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The chronic right hip pain and adjustment disorder, resolved were not profiled or explicitly implicated in the commander’s statement and were not judged to fail retention standards.  

Chronic Right Hip Pain.  A note dated 21 September 2007 indicated the CI had right hip pain with a full ROM unless weight bearing.  His gait and stance were normal.  A bone scan dated 21 September 2007 indicated no right hip or pelvic lesions were present.  An MRI in January 2008 revealed mild right sub trochanteric (below the site where the head and neck of the femur meet) sclerosis (bone thickening), possibly from a stress reaction given the CI’s clinical symptoms, while an right hip X-ray series was normal on 8 April 2008.  A bone scan in April 2008 did not reveal any right hip uptake.  A NARSUM addendum dated 2 February 2009 indicated the CI reported than his right hip pain was problematic and it developed when he had to off-load his left hip because of its pain.  However, at the time of the addendum he denied any pain in the right hip and denied any acute injury to the right hip and noted that it was not as bad as the left hip.  On examination there was no tenderness to palpation; his gait was normal; and there was a normal ROM and normal strength.  The diagnosis of right hip pain, intermittent was made.  No VA C&P examination was performed.

Adjustment Disorder, Resolved.  A note dated 11 December 2009 indicated the CI was in course of evaluation where he noted a depressed mood due to physical limitations from hip pain, miscarriage of a child in June 2008, and relationship/conflict issues with his mother.  The NARSUM dated 11 December 2008 noted the CI had an adjustment disorder with a depressed mood without suicidal or homicidal ideation and he was referred for counseling.  A psychiatric memorandum to the MEB NARSUM dated 4 February 2009 indicated the CI had a diagnosis of bipolar disorder at age thirteen and was on medication for a year; and, he was seen by an off-post therapist since December 2008 for symptoms of irritability, anxiety, and depressed mood in the setting of dealing with chronic pain and occupational stressors.  The CI denied having significant symptoms at the time of the memorandum and did not required medication management for psychiatric symptoms.  Based on the commander’s performance and functional statement, the CI did not have any deficits in industrial capacity and did not appear to be of imminent threat to self or others.  His Global Assessment of Function (GAF) score was 80 (If symptoms are present, they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning.).
	
The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that any of the conditions significantly 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 any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic left hip pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended chronic right hip pain and adjustment disorder resolved conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140610 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 AR20160007936 (PD201402802)

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