RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03931
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20070820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E-3, Unit Supply Specialist, medically separated for “chronic bilateral hip pain, due to femoral neck stress fractures” with a disability rating of 0%.

CI CONTENTION:  “Please 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 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 - 20070625	VARD - 20060608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Hip Pain, due to Femoral Neck Stress Fractures	5022	0%	Tendonitis, Left Hip	5024	10%	20060505	
			Tendonitis, Right Hip	5024	10%	20060505	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:   

Bilateral Femoral Neck Stress Fractures.  The PEB combined the right and left hip conditions under a single service disability rating, coded 5022 (periostitis, defaulting to criteria of 5003) and rated 0%, with likely application of Army Regulation (AR) 635-40 (B-24, f).  This approach by the PEB not uncommonly reflected its judgment that the constellation of hip conditions was unfitting and that there was no need for separate fitness adjudications. The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under VASRD 5003 criteria, and that this approach does not necessarily compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was therefore directed at determining whether the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting or be found unfit because of physical disability.

The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented an onset of bilateral hip pain in November 2004 after a fall during basic training.  A bone scan soon afterwards was consistent with bilateral stress fractures of the femoral necks (near hip sockets), although these were not detected by serial X-rays over the ensuing clinical course.  There was STR documentation of normal gait and grossly normal hip range of motion (ROM), with no documentation of significant ROM limitation or other functional limitations.  There were entries about a year after the injury that the hip pain was resolved with full painless ROM, and “no pain with all functional activity.”  There was no contrary evidence in outpatient STR entries until the examinations that follow.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for a Medical Evaluation Board (MEB) which in turn forwarded “chronic bilateral hip and pelvic pain status-post stress fractures of the femoral neck” to the PEB.

A VA Compensation and Pension (C&P) examination in 05 May 2006 (16 months before separation) documented “chronic aching” bilateral hip pain with flares (2-3/week) rated 7-8/10 “precipitated by physical activity ... [but] ... able to perform his job and activities of daily living.”  The physical examination recorded a normal gait and lower extremity strength (no comment of joint tenderness).  Measured ROM “on repetitive motion testing” (all bilateral) was flexion to 100 degrees (normal 125, 45 for minimum 10%) and external rotation to 20 degrees (normal 45, 15 for minimum 10%), specifying “reports pain with motion.”

The MEB NARSUM examination on 30 April 2007 (4 months before separation) documented “pain in his hips is constant and 8-9/10 in intensity” and was aggravated by lifting and running.  The physical examination recorded a normal gait and the absence of hip tenderness.  Measured ROM was flexion to 80 degrees left and 85 right, extension to 15 degrees left and 20 right (normal 20, 5 for minimum 10%), bilateral external rotation to 20 degrees, abduction to 30 degrees left and 35 right (normal 45, 10 for minimum 10%), and adduction to 35 degrees left and 40 right (normal 45, “cannot cross legs” [~10 degrees] for minimum 10%); specifying painful motion.  The commander’s performance statement did not provide evidence probative to separate fitness implications of either hip and the profile indicated “bilateral hip pains.”

The Board directed attention to its rating recommendations based on the above evidence.  The PEB rated the bilateral hip condition 0%, coded 5022 (periostitis).  The VA rated each hip 10%, coded 5024 (tenosynovitis) based on the C&P examination 16 months before separation, citing painful motion.  The Board agreed a bilateral rating of 0% does not comport with VASRD §4.71a which confers a 10% rating under 5003 for the involvement of “2 or more major joints”.  The Board determined the evidence did not support a compensable rating under any of the codes for hip limitation of motion; and, there was no ankylosis, fracture deformity, flail joint or instability, nonunion/malunion, that would achieve separate ratings higher than 10%.

The Board was thus left with deciding whether the hips were reasonably justified as separately unfitting as a basis for recommending a bilateral 10% or separate 10% ratings.  In this case, there was no evidence that one joint caused more functional impairment than the other, and the overall functional impairment interfered with MOS requirements.  Members agreed, given the pathology and clinical acuity described above, that it would be overly speculative to conclude that the impairment confined to a single hip would have permitted adequate performance within the MOS.  Each hip was therefore reasonably conceded as separately unfitting, justifying separate ratings; and, there was sufficient evidence of painful motion (VASRD §4.59) to support the minimum 10% rating for each joint.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends separate 10% ratings for each hip under code 5022.

BOARD FINDINGS:  In the matter of the chronic bilateral hip pain, due to femoral neck stress fractures condition, the Board unanimously recommends that each joint be rated as separately unfitting at 10%, each coded 5022 VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Hip, Femoral Neck Stress Fractures	5022	10%	
Right Hip, Femoral Neck Stress Fractures	5022	10%	
COMBINED w/ BLF	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140805, 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

08 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018226  (PD201403931)

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