RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03650
BRANCH OF SERVICE:  Army                                                                  SEPARATION DATE:  20080908

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a mobilized for initial entry training Army National Guard E3, Basic Soldier, medically separated for “right hip stress fracture” with a disability rating of 10%.

CI CONTENTION:  The CI requests the Board 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 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 - 20080611	VARD - 20090617	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Hip Stress Fracture	5299-5255	10%	Residuals Right Hip Stress Fracture, Status Post Surgical
Procedure	5252	10%	20090427	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Right Hip Stress Fracture.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hip and groin pain began during Advanced Individual Training (AIT) approximately 7 months prior to referral for MEB.  Right hip diagnostic imaging (X-ray) showed subtle changes of the femur consistent with a stress fracture (repetitive stress induced fracture).  At a 10 December 2008 orthopedic surgery evaluation the CI complained of a 2-month history of right hip and groin pain.  

Right hip diagnostic imaging magnetic resonance imaging (MRI) showed a right inferior femoral neck compression sided (inferomedial aspect) stress fracture with a fracture line extending at least 1/3 of the way through the neck.  Because of the risk of a completed fracture displacement causing avascular necrosis (lack of blood supply causing bone death), the orthopedic surgeon recommended prophylactic pinning.  On 11 December 2008, the CI underwent prophylactic in situ pinning of her right nondisplaced femoral neck fracture.  A right hip X-ray showed interval placement of 3 tension screws traversing the right femoral neck stress fracture.  The physical therapy (PT) measured active range-of-motion (ROM) values were flexion of 100 (125 normal), abduction of 20 (45), and external rotation of 20 (45) degrees.  In the 20 May 2008 NARSUM, 4 months before separation, the CI reported she suffered a right hip injury on the last day of basic training when she tripped or stumbled.  She reinjured it when slipped again and fell after reporting to Fort Gordon.  Following prophylactic pinning of her right femoral neck fracture, her incision healed, but she continued to have pain.  The CI complained of constant 7/10 pain in spite of aggressive PT.  Pain was exacerbated by bending, squatting, lifting, standing, walking, and stairs and was relieved by medications.  Symptoms interfered with sleep and required use of a cane.  The examiner referred to the DD Form 2808.  The physical examination documented an antalgic (assuming a gait or posture to lessen pain) gait with a limp involving the right hip.  The right hip examination revealed a well-healed surgical scar, tenderness over the greater trochanter (proximal lateral femur bony prominence), and no evidence of muscle atrophy.  The right lower extremity examination revealed good muscular strength and development and no neurosensory deficits or changes.  The flexion, abduction, external rotation, and extension ([FABERE] assesses hip and sacroiliac joint pathology) test was positive with pain referred to the hip.  Goniometer measured repetitive (X3) active ROM values were flexion of 100 (125), extension of 10 (20), abduction of 20 (45), adduction of 20 (45), and external rotation of 20 (45) degrees.  The ROM was limited by pain, but there was no addition limitation due to fatigue, weakness, or lack of endurance with repetitive use.  The diagnosis listed chronic right hip pain status-post surgical repair of stress fracture.  A bilateral hip X-ray was normal, except for 3 screws traversing the right femoral neck, with no evidence of hardware failure or loosening.  In the 27 April 2009 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI complained of progressively worsening and constant right hip pain with associated stiffness and weakness.  She denied deformity, giving way, instability, incoordination, dislocation, subluxation, locking, effusion, or flare-up.  Pain was exacerbated by prolonged standing, walking, lifting, and carrying and was relieved by medications.  Symptoms interfered with sleep on her right side and required use of a cane.  The physical examination documented an abnormal gait with a slight limp.  There was guarding of movement and no evidence of inflammatory arthritis.  Repetitive active ROM values were flexion of 120 (125), extension of 30 (20), abduction of 35 (45), adduction of 25 (45), and external rotation of 50 (45) degrees.  There was no additional limitation of motion due to pain, fatigue, weakness, or in coordination with repetitive use.  Strength, sensation, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  A right hip X-ray was normal except for 3 screws in the proximal right femur.  The diagnosis listed residuals right hip stress fracture status-post surgical procedure.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5255 code (femur, impairment of) citing right hip stress fracture, subsequent screw fixation, persistent pain, no malunion of the femur, slight hip disability, ROM, and no additional limitation of ROM from pain, fatigue, weakness, lack of endurance, or incoordination following repetitive use.  The VA assigned a 10% rating under the 5252 code (thigh, limitation of flexion of) based on the VA C&P examination 8 months after separation, citing right hip stress fracture, status-post surgical repair, chronic pain, gait with slight limp and guarding of movement, ROM, and no additional limitation of ROM from pain, fatigue, weakness, lack of endurance, or incoordination following repetitive use.  While the CI underwent right hip prophylactic pinning, postoperative X-rays were normal except for retained hardware.  There was no evidence of nonunion or malunion for consideration under 5255 (femur fracture nonunion/malunion of).  
There was no compensable limitation of motion for consideration under 5251 (thigh, limitation of extension of) or 5252 (thigh, limitation of flexion of).  There was no evidence of disability for consideration under 5250 (hip, ankylosis of), 5253 (thigh impairment of abduction, adduction, rotation of), or 5254 (hip, flail joint).  Board members agreed a 10% rating was justified IAW §4.40 (functional loss) and §4.59 (painful motion).  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 right hip stress fracture.

BOARD FINDINGS:  In the matter of the right hip stress fracture 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 20140730, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017195 (PD201403650)

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