RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03533
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090809

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard, E3, Small Arms/Artillery Repairer, medically separated for “stress fracture of left hip,” with a disability rating of 20%.

CI CONTENTION:  The CI contends 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 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 - 20090714	VARD - 20091030	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fracture, Left Hip	5255	20%	Stress Fracture, Left Hip	5255	20%	20090316	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Stress Fracture of Left Hip.  The service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 28 May 2009 indicated the CI fell from her bunk during basic training on 23 June 2007 and hit her pelvis on a metal bar across the bunk.  After a run 2 days later, she could barely get out of bed because of pain in her left hip.  Treatment consisted of crutches, pain medication and physical therapy.  A bone scan dated 28 June 2007 revealed a focal hot uptake at the left mid sacroiliac (SI) joint and a mini lesion was also noted at the left inferior pubic ramus.  An X-ray series of the pelvis did not demonstrate a stress fracture on 12 July 2007 and a left hip series on 23 July 2007 showed no evidence for an acute osseous abnormality and no evidence for a stress fracture.  The clinical diagnosis was compression arthralgia-pelvis/hip/femur.  Within 2 weeks she was able to pass a physical fitness test; however, she noted pain after climbing up into a 5-ton truck.  For the residual pain, she resumed the rehabilitation and physical therapy and was released to return to normal military activities in early August 2008.  After physical training for a week in early October 2008 she had right hip pain.  A bone scan dated 22 October 2008 showed multiple stress fractures with focal uptake in the left superior SI joint and both legs.  Bilateral hip X-rays on 4 November 2008 revealed no acute osseous findings involving the bilateral hips, but there was a likely transition lumbosacral vertebra with a suggestion of a pseudoarthrosis involving its left transverse process, which could have been the source of pain.  An orthopedic evaluation on 4 November 2008 indicated the CI had bilateral hip pain with clicking for 2 years.   A magnetic resonance image arthrogram of each hip was performed on 17 December 2008, which revealed an intact labrum of each hip and no osseous abnormalities or fractures.  In January 2009 the CI reported her left hip was still bothersome to walk despite pain medication, rest and crutches. 

A permanent L3 profile was issued for chronic left hip pain on 19 February 2009.  The commander’s statement dated 5 June 2009 indicated she could not perform her military specialty since she could not lift or manipulate heavy weapons in order to do her job.  She performed some administrative work and worked 40 hours a week, but she was unable to complete a physical fitness test because of her profile limitations.   

At the VA Compensation and Pension (C&P) examination in March 2009, performed 5 months before separation, the CI reported painful hips, the left worse than the right.  On examination the CI walked with a left antalgic gait and could not sit in one position for more than 10 minutes.  She did not use any assistive devices.  Lumbar spine flexion was 80 degrees and the combined range of motion (ROM) was 200 degrees.  The left hip motion was active and painful as recorded in the chart below.  

The NARSUM author noted in May 2009 that most of the CI’s pain was in the left lateral hip, but there was also pain in the groin extending to the pubis and coccyx.  The lateral hip/groin pain ranged from 4-5/10 (10 being the worst pain) and increased to 7/10 in the evening/bedtime and the pain sometimes awakened her from sleep.  Walking was limited to about a half mile; and she could not run at all.  Prolonged sitting, cold and damp weather, and fatigue worsened symptoms.  Occasional symptoms in the right hip were believed to be due to compensation for the left hip.  On examination the CI’s gait was normal; her pelvis was level; and she walked on her heels and balls of both feet.  She was sore to firm palpation over the symphysis pubis, the left anterior hip/groin, and on the left greater trochanter.  Passive internal rotation was painful especially on the left.  There was no motor weakness at the hip, and there was no visible muscle atrophy.  When the CI performed forward flexion with her knees extended, her finger tips reached about 15 cm below her knees.  

The 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)	PT ~7 Mo. Pre-Sep	VA C&P ~5 Mo. Post-Sep	MEB ~3 Mo. Pre-Sep	
Flexion (125 Normal)	125	110	90	
Extension (20)	0	10	0	
External Rotation (45)	40	40	40	
Abduction (0-45)	40	35	40	
Adduction (45)	40	30	30	
§4.71a Rating	10%	VA 20%	PEB 20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under code 5255 (femur impairment with moderate knee or hip disability) based on the VA proposed rating under the IDES (Integrated Disability Evaluation System) Pilot Program for a stress fracture of the left hip.  The VA assigned a 20% rating using code 5255 for a stress fracture of the left hip.  The Board sought a route for a higher rating, but was unable to find one in the absence of hip ankylosis, thigh flexion to 20 degrees or less, hip flail joint, hip fracture with nonunion, or malunion with marked hip disability.  At the time of separation there was no evidence of degenerative changes; however, since a bone scan demonstrated a finding that was most consistent with a stress fracture of the left superior sacroiliac joint, Board members discussed VASRD §4.45 (the joints) and VASRD §4.66 (sacroiliac joint) as well as code 5236 (sacroiliac injury and weakness), which is rated under the General Rating Formula for Diseases and Injuries of the Spine.  However, neither the MEB nor the VA examinations offered a thoracolumbar ROM that provided an option for 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 stress fracture of the left hip condition.  

BOARD FINDINGS:  In the matter of the stress fracture of the left hip 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 20140724, 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 AR20160008179 (PD201403533)

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