RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03894
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090303

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Preventive Medicine Trainee, medically separated for “chronic right hip pain and right sacroiliitis,” with a disability rating of 10%.

CI CONTENTION:  “My condition has got much worse.  I have been diagnosed with severe degenerative joint disease of right hip and peripheral nerve trauma.  I have recently been approved for social security because of my severe pain, severe degenerative arthritis and nerve trauma.”  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 based upon a 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 - 20081230	VARD - 20090411	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Hip Pain and Right Sacroiliitis	5099-5003	10%	Right Femoral Acetabular Impingement	5252-5024	10%	20090115	
			Surgical Scars, Right Hip	7805	0%	20090115	
			Chronic Right Sacroiliitis	5236	0%	20090115	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Right Hip Pain and Right Sacroiliitis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery (arthroscopic debridement), but afterwards was diagnosed with joint impingement and underwent a second procedure (open acetabuloplasty and labral re-fixation) in April 2008, 11 months prior to separation.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic right hip pain status post arthroscopic surgery” and “right sacroiliitis” for PEB adjudication.

The NARSUM examination on 14 October 2008, 5 months before separation, documented chronic hip pain “present approximately 90% of the time” aggravated by standing longer than 15 minutes, lifting and loadbearing, and prohibiting running, jumping and marching.  The right sacroiliac (SI) pain was described as “present 70% of the time, increased with ambulation and with prolonged sitting.”  The physical examination recorded an antalgic gait and use of a cane, tenderness of the right hip and SI joint, and normal strength of the right leg.  Measured right hip range of motion (ROM) was flexion to 95 degrees (normal 125, 45 for minimum 10%), extension to 10 degrees (normal 20, 5 for minimum 10%), external rotation to 40 degrees (normal 45, 15 for minimum 10%), abduction to 35 degrees (normal 45, 10 for minimum 10%), and adduction to 20 degrees (normal 45, 10 degrees for minimum 10%) noting “cannot cross legs”.  Measured thoracolumbar ROM was normal in all planes (flexion 90 degrees, combined 240) without specifying painful motion.  An STR orthopedic entry 2 weeks after the NARSUM documented post-operative improvement, a “slight antalgic gait,” and grossly normal hip ROM.  A later physical therapy (PT) entry, 6 weeks before separation, recorded a “slow, non-antalgic gait that appears stiff.”

At the 15 January 2009 VA Orthopedic Compensation and Pension (C&P) examination, performed 2 months before separation, chronic pain in the right SI joint and hip was documented, as well as the right knee and ankle; however, the doctor did not elaborate pain severity or apportion functional impairment among the multiple orthopedic conditions.  Overall limitations included prolonged sitting, standing, and walking (15 minute tolerance); but, there was no impairment of daily activities.  The physical examination recorded a “limp” favoring the right leg and use of a cane (in the context of all conditions), the absence of hip or SI tenderness, and normal leg strength.  Measured right hip ROM was flexion to 90 degrees, extension to 20 degrees, external rotation to 45 degrees, abduction to 30 degrees, and adduction to 15 degrees.  Measured thoracolumbar ROM was normal in all planes, specifying pain with extension and right rotation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating, analogous to 5003 (degenerative arthritis), was consistent with VASRD §4.71a criteria for the service evidence, although the hip and SI conditions were subsumed in the same rating.  The VA, based on the C&P evidence, conferred separate ratings for the hip and SI joint, rating 10% under code 5252-5024 (limitation of flexion – tenosynovitis) for the hip, citing painful motion; and, 0% for the SI condition coded 5236 (sacroiliac injury and weakness).  The 5236 code is the clinically appropriate code and defaults to rating under the VASRD §4.71a general spine formula; and, the VA 0% rating decision cited the normal thoracolumbar ROM criteria.

The Board’s first determined is if the PEB approach of consolidating the hip and SI diagnoses for rating as a single unfitting condition was fair in lieu of separate ratings.  Although the sacroiliitis was apparently a complication of the hip injury, they were clinically distinguishable and separate conditions subject to individual VASRD ratings.  The Board provided the following clarification concerning its approach to PEB consolidated ratings.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting and there was no need for separate fitness adjudications.  When considering a separate rating for each condition, the Board considered each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  Members agreed that it would be speculative in this case to conclude that the impairment from the sacroiliitis alone (painful motion at most, without ROM limitation or extremity weakness) would have necessitated a medical separation; and, furthermore, the unfitting pain was inextricably linked with that of the hip condition, as was the attendant disability.  Members thus concluded that a separate SI rating would logically violate VASRD §4.14 (avoidance of pyramiding) rule.  

The Board next considered the fairness of the PEB’s rating for the hip itself.  There was no ROM limitation, ankylosis, flail joint, or instability that would achieve a rating higher than 10% under any alternate code; other than consideration of analogous rating under 5299-5255 (femur, impairment of) which offers ratings for contiguous hip disability: 20% for “moderate” and 30% for “marked.”  Members agreed; however, that the analogous application of this fracture code (with no fracture present) was not justified by VASRD §4.20 (analogous ratings) in a case such as this which satisfies compensable criteria under more applicable joint codes.  

The Board does not recommend disability rating for scars unless their presence imposes a direct functional limitation that renders the CI unfit.  The right hip scars did not interfere with wear of military gear and were not painful at the MEB examination.  Any contribution from the scars on ROM limitation was addressed above.  There was insufficient evidence of duty-limiting impairment from the right hip scars, thus the Board concluded that the scars condition could not be recommended for additional disability 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 of the right hip and sacroiliac condition.  

BOARD FINDINGS:  In the matter of the right hip and sacroiliac 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 20140828, w/attachments
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

07 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
 (PD201403894)

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