RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04170
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20021115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E3, Basic Trainee, medically separated for “chronic pain, status post healed right inferior pubic ramus stress fracture and right ankle due to healed distal fibular stress fracture,” with a disability rating of 0%.

CI CONTENTION:  The CI has submitted a lengthy contention stating that she was given a higher rating for her conditions by the VA.  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 - 20020913	VARD - 20030723	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Status Post Healed Right Inferior Pubic Ramus Stress Fracture and Right Ankle due to Healed Distal Fibular Stress Fracture	5099-5003	0%	Stress Fracture of the Right Inner Pubic Ramus	5299-5252	20%	20030408	
			Pain Residuals, Right Ankle Fracture	5271	10%	20030408	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Pain Status Post Healed Right Inferior Pubic Ramus Stress Fracture.  The PEB combined the “pubic ramus stress fracture” and “the right ankle due to healed distal fibular stress fracture” conditions as a single unfitting condition coded analogously to 5003 and rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  The 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.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not 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 if 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 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.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the pubic ramus stress fracture and the right ankle due to healed distal fibular stress fracture conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s pubic ramus stress fracture occurred in September 2000 during basic training while running.  Despite treatment, the pubic ramus stress fracture could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic right inferior pubic rami pain, secondary to old stress fracture” for PEB adjudication.  

The MEB NARSUM examination was performed on 14 August 2002 (3 months before separation).  The CI reported persistent pain.  The physical examination showed tenderness in the right inguinal area (ischium), and normal strength of hip movements.  There was full range of motion (ROM) of the hip with pain on adduction, internal rotation, and resisted forward flexion of the hip.  At the MEB examination (documented on DD Forms 2807-1 and 2808) dated 26 August 2002, the CI reported “pain with walking, working, and driving.”  The physical examination showed thigh pain (at the right pubic ramus) with resisted adduction.  Profile limitations, dated 20 August 2002, included exercises that caused impact on the hip (hopping, jumping, jogging, unlimited running, etc.).  According to the commander’s statement, dated 20 August 2002, the CI took breaks throughout the day because of her pain, but she was described as a “great asset,” and tried to “do her best,” to “ensure the mission was completed.”  

At the 8 April 2003 VA Compensation and Pension (C&P) examination, performed 5 months after separation, the CI reported pain and stiffness, especially after 8-10 hours of standing at work without rest.  The physical examination showed a normal gait with the ability to get on and off the examination table, and “limited” range of motion of the right hip.  There was tenderness at the right pubic area, flexion to 45 degrees (normal 125) with pain in the right groin, and abduction to 30 degrees (normal 45).  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB bundled both the “chronic right inferior pubic rami pain, secondary to old stress fracture” and the ankle condition, and rated 0% analogously coded 5099-5003 (degenerative arthritis, citing the US Army Physical Disability Agency (USAPDA) Pain Policy.  The VA rated 20% for the “stress fracture of the right inner pubic ramus,” analogously coded 5299-5252 (thigh, limitation of flexion), citing limitation of hip flexion to 45 degrees.  

The Board first considered if the pubic ramus condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, the pubic ramus stress fracture condition was considered to fail retention standards; was implicated by the NARSUM and in the commander’s statement; and was profiled.  The Board concluded that there was a preponderance of evidence of the service records that overcame the Board’s presumption that the bundled pubic ramus stress fracture condition is reasonably considered separately unfitting.  
The Board then considered the rating recommendation for the unfitting pubic ramus condition at the time of separation.  The MEB NARSUM documented painful motion, IAW VASRD §4.40, §4.49, and §4.45 to achieve the minimum rating of 10%.  There was no STR evidence before separation of ankylosis, extension limited to 5 degrees, or flexion limited to 30 degrees in support of a higher rating.  There was no evidence of limitations in abduction (beyond 10 degrees), adduction (inability to cross legs), or rotation (inability to ‘toe out’ to more than 15 degrees) in support of a higher than 10% rating.  There was no documentation of “moderate hip disability” due to malunion for a higher rating under analogous coding (5255).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10%, analogously coded 5010-5252 (traumatic arthritis; thigh, limitation of flexion), for the pubic ramus stress fracture condition.  

Right Ankle Pain due to Healed Distal Fibular Stress Fracture.  According to STR and the MEB NARSUM, the CI’s fibular stress fracture occurred in October 2000 during basic training after stepping into a hole during a march.  The Board first considered if the distal fibular stress fracture condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, the profile included limitations attributable to both the pubic ramus stress fracture and the fibular stress fracture, but not specific for the ankle condition.  The commander’s statement and other STR evidence did not provide any information which would permit the Board to discriminate the performance limitations attributable to the ankle fracture.  The NARSUM listed the right distal fibular stress fracture as “healed” as the examiner found no physical disability and stated that the area of the fracture was “asymptomatic” on examination.  It was forwarded by the MEB and considered to fail retention standards by the PEB in combination with the pubic ramus condition.  After due deliberation, members agreed that the preponderance of the evidence does not support a conclusion that the functional impairment from right ankle condition was integral to the CI’s inability to perform her MOS, and accordingly cannot recommend a separate rating for it.  

BOARD FINDINGS:  In the matter of the pubic ramus stress fracture condition, the Board unanimously recommends a disability rating of 10%, coded 5010-5252 IAW VASRD §4.71a.  In the matter of the right ankle due to healed distal fibular stress fracture condition, the Board unanimously agrees that it cannot recommend a finding of unfit for additional disability rating.  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 her prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain Status Post Healed Right Inferior Pubic Ramus Stress Fracture	5010-5252	10%	
Right Ankle due to Healed Distal Fibular Stress Fracture	5099-5003	Not Unfitting	
COMBINED 	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20160017818 (PD201404170)

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 10% 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