RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00033
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081010

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Intelligence Analyst, medically separated for “left hip labral tear,” “right hip labral tear” and “irritable colon syndrome,” rated 10%, 10% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contends his bilateral hips and PTSD.  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 - 20080703	VARD – 20090108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Hip Labral Tear	5099-5003	10%	No VA Placement	
Right Hip Labral Tear	5099-5003	10%	Labral Tear Right Hip	5252-5024	10%	20071218	
Irritable Colon Syndrome	7319	0%	Irritable Bowel Syndrome …	7346-7319	10%		
Anxiety Disorder	Not Unfitting 	PTSD with Depression	9411	30%	20080108	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Right Hip Labral Tear.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hip condition began in December 2006 without any specific injury.  The CI reported pain in the hip changing positions from sitting to standing.  Right hip X-rays were normal.  Right hip magnetic resonance imaging (MRI) (arthrogram) was read an anterior labral tear (tear of cartilage rim of the joint).  The CI received multiple orthopedic opinions and was offered surgery, but declined since there was no guarantee that he would be fit for full duty following the surgery.  Despite conservative treatment, the right hip condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB dated 19 November 2007 forwarded “chronic right hip pain with femoralacetabular impingement and labral tear” for PEB adjudication.  

At the MEB examination dated October 2007, 12 months prior to separation, the CI reported evaluation of right hip pain.  Physical examination showed decreased range of motion (ROM) of the right hip and pain with flexion and external rotation.  

The MEB NARSUM examination on 15 November 2007, 11 months prior to separation, noted complaints of chronic right hip pain, with pain with changing positions from sit to stand as noted above.  The CI was not using a cane or a crutch.  He reported pain with most activities including running, prolonged walking, sitting, lifting, carrying, biking and swimming.  The pain was helped somewhat by stretching and rest.  He was taking a muscle relaxant.  Physical examination showed a normal gait.  There was no tenderness over the hip.  The right hip ROM of flexion 105 degrees (normal 125 degrees), extension 33 degrees (normal 20 degrees), abduction of 45 degrees (normal 45 degrees), adduction of 30 degrees (normal 45 degrees), and external rotation of 50 degrees (normal 45 degrees).  All ROM was painful.  Reflexes of the lower extremities were normal and straight leg raise testing was negative.  

At the 18 December 2007 VA Compensation and Pension (C&P) evaluation, performed 10 months before separation, the CI reported right hip pain.  The CI reported the same limitations to his activities as noted above.  The physical examination showed a normal gait, without use of assistive devices.  There was no muscle atrophy, strength was graded 5/5 and reflexes were normal bilaterally.  There was no focal tenderness, swelling, or deformity of the right hip.  Hip ROM was flexion of 105 degrees, abduction of 45 degrees.  Flexion was reduced to 80 degrees with pain after three repetitions.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right hip labral tear condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing non compensable ROM with consideration of functional loss.  The VA rated the right hip labral tear condition 10% coded 5252-5024 (thigh, limitation of flexion - tenosynovitis), based on the VA C&P examination 10 months before separation, citing painful motion.  There was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB or 5251 (limited thigh extension), or coded as 5253 (thigh impairment) for “limitation of adduction, cannot cross legs.”  There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh flexion or extension, thigh impairment (5251, 5252, 5253).  There was no evidence of hip ankyloses, flail hip joint, or femur impairment (5250, 5254, 5255) for a rating under the respective codes.  There was therefore no route to a rating higher than the 10% adjudicated by the PEB under any applicable VASRD §4.71a code.  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 condition.  

Left Hip Labral Tear.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left hip condition began in October 2007 after stepping into a hole while walking for physical training.  He twisted his back and left hip and reported pain to the left hip and down to the knee.  Left hip X-rays were normal.  The CI was initially diagnosed with sciatica by family practice and treated with anti-inflammatory and muscle relaxant medication.   The CI appealed the findings of the IPEB on 15 January 2008 and requested inclusion of the left hip in the MEB.  Left hip MRI arthrogram showed the same abnormality as the right hip –tear of the anterior labrum.  The radiologist noted that the defect was symmetrical and in an area not typical for labral tears, which raised the issue if it was an anatomical variant.  The orthopedic specialist felt it was the same diagnosis for both hips, acquired femoral acetabular impingement syndrome and that the MRI arthrogram likely did represent a labral tear of the left hip.  The CI was not a surgical candidate for the left hip at the time because there were no mechanical symptoms.  The MEB forwarded “chronic bilateral hip pain with bilateral labral tears” for PEB adjudication.

At the MEB examination the CI reported both hips as “swollen or painful joints.”  Physical examination did not address the left hip.  The MEB NARSUM examination noted complaints of right hip pain.  Physical examination did not address the left hip except for ROM recorded as hip flexion of 105 degrees, extension of 34 degrees, abduction of 50 degrees, adduction of 32 degrees, and external rotation of 50 degrees.

At the 18 December 2007 VA Compensation and Pension (C&P) evaluation the CI reported pain of the low back that radiated to the left hip, rather than left hip pain.  It was addressed as “sciatica”.  The CI denied neurologic symptoms and had been treated with physical therapy with benefit and was not using medication.  Physical examination noted a normal gait with normal lower extremity strength and reflexes.  There was no examination of the left hip performed.  The VA examination included the thoracolumbar spine, which was not adjudicated by the PEB and is therefore not in the Board’s scope of review.  

At the VA C&P examination on 9 April 2010, 18 months after separation, the CI reported he underwent laparoscopic repair of the labral tear of the left hip in January 2009.  He reported “grinding and popping” at times.  He reported pain with some activities.  He denied flare-ups, the hip was not unstable and he did not use assistive devices for ambulation.  Hip X-rays and MRI since the surgery were normal.  The VA examiner noted the CI had pain and “mild limitation on a functional basis.”  The physical examination showed surgical scars of the left hip.  Hip ROM was flexion of 125 degrees, extension was 0 degrees, external rotation was 40 degrees abduction was 45 degrees, and adduction was 20 degrees.  There was painful motion noted with no additional loss of ROM with repetitions.  No popping was heard during the examination.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left hip labral tear condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing non compensable ROM with consideration of functional loss.  The VA did not service-connect the left hip condition until the VA Rating Decision in July 2010, 22 months after separation, with an effective date of 4 March 2010.  The VA rated the left hip condition 10% based on a C&P examination 18 months after separation.  By the same rationale as elaborated under the right hip rating discussion, the Board concluded that there was no route to a rating higher than the 10% adjudicated by the PEB under any applicable VASRD §4.71a code.  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 left hip condition.  

Irritable Bowel Syndrome.  According to STR and the MEB NARSUM, the CI’s irritable bowel syndrome condition began in 2003 while deployed.  At a family practice visit on 23 August 2006, the CI reported diarrhea 1 to 2 times per day with gas, bloating cramping, and occasional nausea.  He reported he had two colonoscopies which were normal and an upper gastrointestinal (GI) endoscopy which showed esophageal erosions.  He denied blood in his stool or weight loss.  He was concerned about ongoing treatment since he was due to ETS soon.  On examination the abdomen was soft and non-tender.  The CI was referred to an active duty physician for options such as medical extension or permanent profile and the physician indicated he did have any information that warranted either option and recommended treatment with oral medication to slow the GI tract (Imodium).  The CI underwent comprehensive evaluations by multiple GI specialists and was cleared to follow up with family practice, with a flow sheet of interventions to try, none of which were reportedly helpful.  
At the MEB examination the CI reported he “often” had indigestion, was treated for an ulcer and had hemorrhoids.  The CI noted that he had lost 10 pounds from his normal weight and then gained 10 pounds above normal.  The physical examination of the abdomen was normal.  

The MEB dated 19 November 2007 forwarded “irritable bowel syndrome” to the PEB for adjudication.  The Informal PEB adjudicated the IBS as not unfitting.  The CI appealed the PEB findings; a Reconsideration PEB and a Formal PEB upheld the PEB findings.  The CI appealed and requested a reconsideration of the FPEB findings.  A primary care note on 19 May 2008 indicated “his IBS is associated with debilitating diarrhea and his command confirms this” and the CI was given a permanent P3L3 profile.  The MEB dated 22 May 2208 was changed to reflect that the IBS condition fell below retention standards.  

There was no MEB NARSUM addendum in record for the IBS condition.  In a letter to his Congressman dated 12 May 2008 the CI described an approximately 4-year history of his bowel symptoms, without quantitation of frequency or severity of episodes, but noted he had tried to get a permanent profile due to missing work and often being late.  The memorandum to the MEB by his chain of command (noted above under the left hip discussion) is excerpted below regarding the IBS condition.

With regards to his IBS, [the CI] was on temporary and permanent profiles for his condition during the rating period in question.  Although his long restroom breaks would interfere with the time he was able to work, I did not think I should rate him poorly because he was suffering from a condition he could not control.

In the CI’s appeal of the FPEB dated 19 May 2008, his attorney indicated the CI experienced approximately three episodes of diarrhea per day, each of which took him away from work for 30 to 45 minutes.

In the PEB’s response to the CI’s appeal for reconsideration dated 10 June 2008, the PEB indicated that the IBS condition was determined to be unfitting because “it might interfere with duty in a field environment.  However, it is appropriately rated as mild in that three bowel movements a day is within normal range.” 

At an evaluation by an allergy specialist on 12 June 2007, the CI reported 10-15 BM per day and the examination noted that the abdomen was diffusely tender.  Tests for food sensitivities and Celiac disease (malabsorption disease) were negative.  A case management note dated 19 June 2007 indicated that the CI was weighing surgery on his right hip, which he was told “may” produce 85% improvement and freedom from pain.  He was not sure he wanted to have surgery.  The CI discussed wanting to talk with his primary care provider about whether post-traumatic stress disorder symptoms (see MH condition discussion below) might be related to his IBS.  

The commander’s response to the Congressional inquiry on the CI’s behalf, dated 8 July 2008 indicated that the PEB rated the condition as mild because “his condition has been present for several years and it did not significantly interfere with his performance.”

At the 18 December 2007 VA Compensation and Pension (C&P) evaluation, performed 10 months before separation, the CI reported chronic diarrhea and abdominal cramping.  He had tried multiple medications in the past without benefit and was on no therapy for the condition at the time of the examination.  He was on profile with a requirement to have access to a bathroom at all times, with no other physical restrictions reported.  The CI also reported residual gastroesophageal reflux disease (GERD) symptoms with no treatment at the time.  Physical examination showed a thin male who did not appear to be in pain.  The abdominal examination was without masses or tenderness.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the irritable bowel syndrome condition 0%, coded 7319 (irritable colon syndrome), citing bouts of urgent bowel function.  The VA rated the irritable bowel syndrome condition 10% coded 7346-7319 (hernia hiatal-irritable colon syndrome), based on the VA C&P examination 10 months before separation.  

The Board noted that the rating criteria of 7319 are somewhat subjective with a 0% rating for “mild; disturbances of bowel function with occasional abdominal distress,” a 10% rating for “moderate; frequent episodes of bowel disturbance with abdominal distress,” and 30% for “severe; …with more or less constant abdominal distress.”  The record documented an exacerbation of IBS symptoms in June 2007 while the CI was appealing his Formal PEB and also trying to decide whether or not to have surgery for his hip pain.  Exacerbations of IBS during stressful periods are typical of the disorder.  However, the evidence in record supports that the CI quantified the IBS over a period of years as “2 to 3” or “approximately 3” episodes per day.  The Board noted that this frequency of bowel movement is within the normal range of bowel function.  Although the Board acknowledges that the CI reported abdominal bloating and cramping, the frequency of these symptoms was not clearly documented and only one examination in record (allergy examination) noted the presence of abdominal tenderness.  After deliberation, the Board consensus was that the evidence supported characterizing the IBS as mild within the context of the VASRD rating criteria.  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 irritable bowel syndrome condition.  

Contended PEB Conditions:  Anxiety Disorder.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or judged to fail retention standards.  No MH condition was mentioned in the initial commander’s statement dated 10 October 2007, which recommended the CI be separated from the military due to the right hip condition.  Three NCOER reports for the period July 2004 to end of February 2007 rated the CI’s duty performance highly as noted above.  

The initial mental health MEB NARSUM, dated 13 November 2007, provided an Axis I diagnosis of anxiety disorder, not otherwise specified (NOS) and the MEB psychiatrist determined that the CI’s psychiatric condition did not fall below retention standards.  The MEB psychiatrist noted that it was possible the CI’s anxiety was contributing to his IBS condition.  

After the completion of the Formal PEB, the MEB psychiatrist wrote an addendum dated 6 May 2008 and indicated the CI’s symptoms had worsened according to the CI’s chain of command and the CI, noting examples of “trouble recalling information, e.g. phone numbers, tasks to complete.  He reports he now has to carry a list of things to do.”   The CI was under care with a community MH provider and the MEB psychiatrist also noted he had been diagnosed with PTSD and was involved in regular individual therapy.  The MEB psychiatrist indicated that the CI was prescribed an anti-anxiety medication on that day and would be treated and followed to determine his response and concluded by stating that “with further evaluation and treatment, he may not meet psychiatric retention criteria.”  The senior rater wrote a memorandum to the MEB in May 2008 to explain the discrepancy between his comments noted by the MEB psychiatrist and the CI’s last NCOER evaluation.  The commander noted the CI’s performance declined after the most recent rating period reflected on the NCOER he had signed in January 2008, which is not in record.  He attributed the decline to an increase in the CI’s MH symptoms.  However, there was no performance-based evidence from the record that any MH condition significantly interfered with satisfactory duty performance prior to this period and in May 2008 the MEB psychiatrist still did not determine that the CI’s MH condition failed retention standards, regardless of specific diagnosis.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right and left hip labral tear conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the irritable bowel syndrome condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20150112, 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 
XXXXXXXXXXXXXXXXXX, AR20160018787 (PD201500033)

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