RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03516
BRANCH OF SERVICE:  Army	BOARD DATE:  20150521
Separation Date:  20080425

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2 (Supply Specialist) medically separated for right hip pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The conditions characterized as “right hip pain” and “bilateral bone edema,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were forwarded for adjudication.  The Informal PEB adjudicated “right hip pain,” as unfitting, rated 10%, with application 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 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 20080310	VA* - (~64 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Hip Pain (MEB Dx 2: Bilateral Bone Edema)	5099-5003	10%	Limitation of Extension, Right Hip Bursitis	5019-5251	10%	20130817	
			Limitation of Flexion, Right Hip Bursitis	5019-5252	0%	20130817	
			Impairment of Thigh, Due to Right Hip … 	5019-5253	0%	20130817	
			Limitation of Extension, Left Hip Bursitis	5019-5251	10%	20130817	
			Limitation of Flexion, Left Hip Bursitis	5019-5252	0%	20130817	
			Impairment of Thigh, Due to Left Hip …	5019-5253	0%	20130817	
Other x 0 (Not In Scope)	Other x 14	
RATING:  10%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20130913 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  As noted above, the PEB may have combined the right and left hip bone edema conditions (noted as “MEB Dx 2”) under a single disability rating, coded analogously to 5003; however, there was no mention of the left hip in the disability description text.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Right Hip Pain (Bilateral Bone Edema [swelling]) Condition.  The CI developed right hip pain during Basic Training.  A right hip X-ray was normal while the Bone Scan showed a right hip stress fracture.  A magnetic resonance imaging (MRI) of the bilateral hips showed a right hip stress fracture and large area of swelling; and the left hip showed a stress fracture and a smaller area of swelling.  A repeat bilateral hip MRI showed worsening of the right hip swelling and diminished left hip swelling; however, bilateral hip stress fractures remained.  A repeat bilateral hip X-ray showed a healing stress fracture in the right hip and the left hip swelling with no discrete stress fracture noted.  A third bilateral hip MRI showed an overall progression of the bilateral stress fractures, a decrease in the right hip swelling and an increase in the left hip swelling.  The CI was given a permanent L3 profile for the right hip pain with additional Code C restrictions.  The MEB narrative summary (NARSUM) exam approximately 3 months prior to separation documented that the CI’s chief complaint was “my right hip bothers me,” and there was no report of left hip pain.  She also reported that she could not perform her duties and continue basic because she continued to have hip pain when she performed heavy impact activity despite conservative treatment.  The examiner reviewed the MRI’s and opined that there was no obvious stress fracture seen and there was no indication for surgery.  The examiner diagnosed right hip pain with bilateral bone swelling on MRI.  The MEB NARSUM physical exam findings are summarized in the chart below.  The commander’s statement indicated that the CI’s injury prevented her from performing many physical activities and exercises; he did not specifically state either the right or left hip.  The VA Compensation and Pension (C&P) exam approximately 5 years after separation documented that the CI had bilateral hip pain that radiated down her thighs.  The VA C&P physical exam findings are summarized in the chart below.

There were range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Left/Right Hip ROM
(Degrees)	MEB ~3 Mo. Pre-Sep	PT ~2 Mo. Pre-Sep	VA C&P ~64 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (125 Normal)	110	110	135,136,136	135,135,136	120	120	
Extension (20)	20	20	30,32,32	30,30,30	25	20	
Comment	Strength 5/5; non-tender	Sl tender in R. inguinal/groin area	Pain with any passive ROM; able to cross legs bilat without pain	All ROM with painful motion	
§4.71a Rating	PEB Not Rated (0%)	10%	0%-10%	0%-10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the right hip pain (bilateral bone edema) condition as 5099 analogous to 5003 arthritis, degenerative (hypertrophic or osteoarthritis) and rated at 10%.  The VA rated each hip separately at 10% each, coded 5019-5251.  The remote VA exam was considered potential after separation worsening and the Board adjudged that the exams had the highest probative value for rating.

The Board first considered if the left hip were unfitting and separately ratable.  The NARSUM and MEB indicated that the bilateral bone edema condition did not meet standards, and the PEB listed “MEB Dx 2” under the unfitting disability description (MEB Dx 2 was bilateral bone edema).  Given the inclusion of the MEB Dx 2 on the PEB-rated condition, the Board applied the “reasonably unfitting” standard versus the “preponderance of the evidence” required for a condition found as “not unfitting” by the PEB.  Earlier profiles had included both hips, although the final profile was for only the right hip.  The commander’s statement did not specify either hip, but noted inadequate recovery from stress fractures, and histories and complaints proximate to separation often included both hips.

The MEB NARSUM examiner documented that the CI reported right hip pain and there was bilateral bone swelling.  The evidence indicated that the right hip was associated with more disability than the left one; however, the left hip was worsening closer to separation.  It was also difficult to separate the duty limitations from paired joints, as either or both hips would have the same limitations.  There was limited indication in the service treatment records that the left hip had painful motion, however, the exam closest to separation noted pain on passive ROM.  VASRD §4.71a specifies for 5003 that satisfactory evidence of painful motion for limitation of motion and specifies application of a 10% rating “for each such major joint or group of minor joints affected by limitation of motion” and VASRD §4.59 Painful motion provides a justification for a 10% rating for each major joint with painful motion.  The right hip had evidence of tenderness and the PEB conceded painful motion (IAW §4.59) for the right hip.  Limitations of right hip ROM were not compensable above the 10% rating level for any hip or thigh code.

The Board unanimously adjudged that the left hip condition was conceded as reasonably separately unfitting, and the Board consensus was that there was sufficient evidence for a 10% left hip rating IAW §4.59.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a for the right hip condition; and by a majority a 10% rating coded 5099-5003 IAW VASRD §4.71a for the left hip 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 bilateral right hip pain (bilateral bone edema) condition and IAW VASRD §4.71a, the Board by a majority vote recommends that each joint be separately adjudicated as follows:  an unfitting right hip condition coded 5099-5003 and rated 10%, and an unfitting left hip condition, coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Right Hip Pain	5099-5003	10%	
Left Hip Pain 	5099-5003	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140721, 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 XXXXXXXXXXXXXXXXXX, AR20160002830 (PD201403516)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA