RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02918
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060414

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Medical Specialist Trainee, medically separated for “chronic pain, due to left inferior pubic ramus stress fracture,” with a disability rating of 20%.

CI CONTENTION:  “Please consider all conditions.”  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 including PTSD in this case 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 - 20060406	VARD - 20061010	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, due to Left Inferior Pubic Ramus Stress Fracture	5099-5003	20%	Residuals of Pubic Bone Fracture	5299-5255	10%	20060613	
Adjustment Disorder	Not Unfitting	Depression	9434	30%	20060613	
Abnormal Pap Smear	Not Unfitting	Vaginal Cancer	7599-7528	NSC	20060613	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Pain, Due to Left Inferior Pubic Ramus Stress Fracture.  According to service treatment records and Medical Evaluation Board (MEB) narrative summary (NARSUM), on 19 October 2005, the CI complained of left groin pain for 4 days while in basic training.  A bone scan dated 20 October 2005 demonstrated focal uptake at the left inferior pubic ramus consistent with a stress fracture.  It was believed the CI could continue with training safely with a minimal profile; and, she went on convalescent leave at the end of November 2005.  However, an emergency room note dated 20 July 2006 indicated the CI had used crutches for 4 months.  

The NARSUM, dated 17 February 2006, reported the CI’s symptoms improved but reoccurred after she returned to impact activities including running, jumping, or marching.  She was unable to complete advanced individual training (AIT).  On examination, the CI had an antalgic gait favoring the left lower extremity and she used crutches for ambulation.  There was a negative log roll (to assess for hip pathology), negative heel tap (to determine possible fracture of the lower extremity), mild increased pain with straight leg raise, and positive Faber’s test (to test hip function).  Passive range of motion (ROM) of the hip was 110 degrees of flexion, 60 degrees of external rotation, 40 degrees of internal rotation, 60 degrees of abduction and 20 degrees of extension with increased pain at the upper limits of all ranges.  X-rays demonstrated a small callous formation about the left inferior pubic rami, and a bone scan demonstrated increased signal uptake about the left inferior pubic ramus.  Despite conservative and non-operative management, the CI continued to have debilitating groin pain and could not be adequately rehabilitated to meet the physical requirements of her military specialty and was referred for an MEB.  The MEB forwarded “stable left inferior pubic rami stress fracture” for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated January 2006, 3 months prior to separation, the CI reported she fractured her pubic bone in November 2005 in basic training.  The MEB physical examiner noted tenderness of the left hip/pubis.  

The VA Compensation and Pension (C&P) examination, dated 13 June 2006, was performed 2 months after separation, but was not available for review.  Information was derived from the VA Rating Decision (VARD) dated 10 October 2006, which documented CI complaints of recurrent pain in the lower pelvis and upper inner left thigh, worse with prolonged standing or walking.  On examination, pain was noted with palpation near the site of the fracture as well as with elevation and rotation of the left leg.  X-rays failed to reveal any fracture.  The diagnosis was residuals of pelvic bone fracture and the condition was considered reflective of a slight functional limitation.  
                                                                                                  
The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 20% rating IAW the Army pain policy using code 5099-5003 (arthritis, degenerative) for chronic pain due to left inferior pubic ramus stress fracture.  The VA assigned a 10% rating using code 5299-5255 (femur, impairment) for residuals of pubic bone fracture.  The Board sought a route to a higher rating, but was unable to do so in the absence of hip ankylosis (5250), thigh limitation of flexion (5252), or a hip flail joint (5254).  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 pain, due to the left inferior pubic ramus stress fracture condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that adjustment disorder with a depressed mood and an abnormal Pap smear 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 adjustment disorder and abnormal Pap smear were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.   

Adjustment Disorder with a Depressed Mood.  (An adjustment disorder is not considered a physical disability, however, other conditions that are potentially disabling were mentioned in the record). A note dated 20 January 2006 indicated the CI was referred for medication evaluation for depressive symptoms in “the context of multiple medical problems” and she had social difficulties throughout AIT.  She reported initial and middle insomnia, social isolation, and anhedonia, but denied suicidal ideation.  Mental status findings including a dysphoric mood, tearful affect, and impaired insight.  Trazodone (an antidepressant) was prescribed.  A note dated 5 March 2006 had an assessment of adult sexual abuse and referred to a visit dated 2 March 2006, which is not in the service treatment record.  The CI wrote a note dated 8 March 2006 that indicated as of 2 March 2006 she was treated for depression with Zoloft (antidepressant).  A summary of all of the CI’s treatment revealed visits with diagnoses and combinations of diagnoses beginning in November 2005 through April 2006 of an adjustment reaction, adjustment reaction with depressed mood, acute stress reaction, adult sexual abuse, depressive disorder and posttraumatic stress disorder; however, treatment records were unavailable for review.   A VA C&P examination for mental disorders on 13 June 2006 revealed a neatly groomed CI with a constricted affect and dysphoric mood, who was alert to person, time and place and had no delusions or hallucinations.  She had no suicidal or homicidal thoughts and had normal memory.  The Axis I diagnosis was depression secondary to a sexual assault that took place in January 2006 and her Global Assessment of Functioning was 60 (moderate symptoms).  

Abnormal Pap Smear.  A report dated 23 October 2005 indicated the CI had a cervical Pap smear that was interpreted as a low grade squamous intraepithelial lesion (LGSIL), also known as CIN 1 (cervical intraepithelial neoplasia 1) caused by a human papilloma virus (HPV). The LGSIL was treated with a loop electrosurgical excision procedure (LEEP).  A Pap smear in February 2006 revealed atypical cells of undetermined significance.  HPV testing was to be performed.  

The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that either 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 either of the contended conditions; and, so no additional disability ratings are recommended. 

BOARD FINDINGS:  In the matter of the left inferior pubic ramus stress fracture condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder with a depressed mood and an abnormal Pap smear 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 20140616, 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 AR20160008650 (PD201402918)

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