RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXXXX	CASE: PD-2014-03193  
BRANCH OF SERVICE:  Army	SEPARATION DATE: 20080515  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Health Care Specialist) medically separated for “compression-sided left femoral neck stress fracture” rated 10%.

CI CONTENTION:  The CI requested that the Board review all conditions.  The 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 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:  

 IPEB – Dated 20080313	VA* - 1 month Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Compression-Side Left Femoral Neck Stress Fracture	5099-5003	10%	Residuals of Left Femoral Neck Fracture with Bilateral Anterior Knee Pain	5299-5255	10%	20080602	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7 	
RATING:  10%	COMBINED RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20080806 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Compression-Side Left Femoral Neck Stress Fracture.  The service treatment record (STR) had very limited primary source material related to the left hip condition.  A physical therapy note dated 17 October 2007 indicated the CI completed 6 weeks of basic training and complained of left hip/pelvic area pain for 10 days that was caused by marching and was described as aching, sharp, and deep.  She reported taking ibuprofen (a nonsteroidal anti-inflammatory drug) and calcium and was using crutches for a stress fracture.  On the Report of Medical History (DD Form 2807-1) dated 10 August 2007, the CI did not annotate or mark any issues related to her left hip nor did the examiner record any details specifically related to the left hip on the Report of Medical Examination (DD Form 2808) dated 10 August 2007.  A permanent L3 profile was issued on 9 January 2008 for the left femoral neck stress fracture with limitations of all military activities including no running, no jumping, and no physical training.  Additionally, the CI was required to use crutches.

The MEB narrative summary (NARSUM) dated 30 January 2008 noted the CI was referred to orthopedics for evaluation of a left femoral neck stress fracture in October 2007.  She was placed on non-weight bearing crutches, but there was no significant improvement in the localized pain in her left groin, which she described as 6/10 in intensity (10 being the worst pain) and was worse with hip flexion and abduction.  As a result she had difficulty keeping up with her training company and navigating stairs in her barracks.  Physical examination revealed a positive FABER test (a provocation test to identify the presence of hip pathology).  The CI had pain with extremes of internal and external rotation.  Range-of-motion (ROM) measurements of the left hip performed by a physical therapist on 14 January 2009 were as follows:  extension 15 degrees, flexion 120 degrees, adduction 30 degrees, abduction 45 degrees, internal rotation 45 degrees and external rotation 45 degrees.  The ROMs were painful in all directions.  The CI had an antalgic gait with decreased stance on the left lower extremity and a three-point gait with crutches.  Magnetic resonance imaging dated 7 January 2009 was read as a cortical break on the compression side of the femoral neck with abundant callus.  X-rays of the hip dated 8 January 2009 demonstrated a periosteal reaction around the compression side of the femoral neck, but no cortical break or extension through the femoral neck, which confirmed the diagnosis of a compression-side left femoral neck stress fracture.  The commander’s statement dated 27 February 2008 indicated she was unable to complete her initial entry training and had never taken a physical fitness test “due to her injuries.”

At the VA Compensation and Pension (C&P) examination dated 3 June 2008, performed less than a month post-separation, the CI complained her left hip was worse than the right hip as a result of a stress fracture of the left femoral neck caused by a fellow soldier falling against her left leg that resulted in her stumbling and falling to the ground during basic training in September 2007.  She was managed with crutches and non-weight bearing on the left lower extremity for approximately four months and was prescribed ibuprofen (a nonsteroidal anti-inflammatory drug), Percocet (acetaminophen and oxycodone, a narcotic) and tramadol (an opioid-like medication).  She underwent physical therapy sessions several times a week with persistence of left hip pain, which she described as a sharp, stabbing-type sensation along the outside of her hip and pain in the left groin region of her hip.  She was able to perform all activities of daily living.  Examination revealed that she ambulated with a fluid gait without evidence of antalgia (a posture to avoid or lessen pain) or a limp and demonstrated a toe and heel walk without weakness and a tandem walk without imbalance.  Her hips were symmetrical without gross deformity or malalignment.  The left hip was tender along the greater trochanteric bursa (outside of the hip) and in the groin area and there was pain with internal rotation of the hip.  The ROM measurements of the left hip were:  extension 15 degrees, flexion 120 degrees, adduction 50 degrees, abduction 25 degrees, internal rotation 70 degrees with pain throughout the rotation and external rotation 70 degrees.  

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 a compression-side left femoral stress fracture.  The VA assigned a 10% rating using code 5299-5255 (Femur impairment) for residuals of left femoral neck fracture with bilateral anterior knee pain.  However, the bilateral anterior knee pain is not within the scope of review.  The Board sought a route to a higher rating.  However, in the absence of ankylosis or limitation of extension, flexion, abduction, adduction or rotation, no higher rating could be found.  The CI did have a stress fracture of the femoral head of the left hip, but there was no nonunion.  Callus formation on X-rays of the hip suggest using an analogous code for malunion, but the record and the ROM measurements do not appear to support a moderate or marked hip disability at the time of separation, which are necessary to award 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 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 20140701, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-00), 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160004403 (PD201403193)

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