RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00540
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070627

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E2, Healthcare Specialist, medically separated for “right femoral neck grade IV stress fracture healing and left pubic rami stress fracture,” with a disability rating of 0%.  

CI CONTENTION:  Her condition continues to worsen and impact her daily activities.  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 - 20070614	VARD – No VA Claim	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Femoral Neck Grade IV Stress Fracture Healing and Left Pubic Rami Stress Fracture	5099-5003	0%	No VA Claim	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Right Femoral Neck Grade IV Stress Fracture Healing and Left Pubic Rami Stress Fracture.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had onset of right hip pain and left-sided pelvic pain while attending Basic Combat Training in January 2007.  She was diagnosed with a right femoral neck grade IV stress fracture and a left pubic rami stress fracture.  The CI had recurrence of pain following return from convalescent leave and was placed on crutches and a soft shoe profile.  Despite treatment, the right hip and left pelvic conditions could not be adequately rehabilitated to meet the physical requirements of the CI’s training/military specialty and the CI was referred for MEB.  The MEB forwarded “left pubic rami stress fracture” and “right femoral neck grade IV stress fracture,” for PEB adjudication.  

At the orthopedic examination dated 9 May 2007, 2 months prior to separation, the CI complained of pain in the right hip and groin.  Physical examination showed an antalgic gait on crutches.  There was pain with right leg flexion past 70 degrees, right leg log roll and right heel tap.  The orthopedic specialist recommended that “due to the severity of her condition this early in her career that it would be in her best interest to go ahead and accept the MEB, get healed and come back at a later date if she is still interested.”  

At the MEB NARSUM examination dated 18 May 2007, 9 days after the orthopedic examination and 1 month prior to separation, the CI reported “that at present she is asymptomatic for pain or discomfort.  She has no feeling of instability and she is currently not taking medication for pain control.”  Physical examination showed the CI presented to the clinic “carrying a pair of crutches.”  There was no lower extremity weakness, muscle atrophy or sensory loss.  The right hip was minimally tender with no left hip tenderness.  The range of motion (ROM) examination showed flexion of 115 degrees (normal 125) in each hip with no change on repetition, but passive flexion to 125 degrees on each side.  Extension was 20 degrees (normal) in each hip, and abduction was 45 degrees (normal 45) in each hip.  The CI could cross each leg and toe out greater than 15 degrees on each side.  Indications of pain limited or mechanically limited ROM was noted as “N/A.”  The CI did not file a VA claim.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the right femoral neck grade IV stress fracture healing and the left pubic rami stress fracture conditions as a single unfitting condition coded analogously to 5003 (degenerative arthritis) and rated 0% citing ROM “full-minimal intermittent“ 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 Board first considered if the right femoral neck grade IV stress fracture healing and the left pubic rami stress fracture, having been de-coupled from the combined PEB bilateral adjudication, remained separately unfitting as established above.  Each condition was separately mentioned on the profile, commander’s statement and as not meeting retention standards on the MEB.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that the unbundled right hip and left hip condition were reasonably considered separately unfitting.  The Board then considered its rating recommendation for the unfitting right femoral neck grade IV stress fracture healing and left pubic rami stress fracture conditions at the time of separation.  

Regarding the right hip condition, there was no compensable limitation of hip motion under codes 5250 thru 5253.  However, there was clear objective evidence of painful motion causing functional loss (based on §4.59, §4.40 and §4.45) at the orthopedic examination and continued tenderness at the NARSUM examination with active ROM less than passive ROM to warrant a 10% rating analogous to code 5255 (Femur, impairment of) for slight hip disability.  

Regarding the left pubic ramus fracture condition, the Board considered VASRD §4.67 (Pelvic bones); there were no residuals of faulty posture, painful lumbar spine motion, tenderness, sciatic neuritis or peripheral nerve injury, and the Board therefore considered if the limitation of left hip motion (flexion) was compensable.  There was no compensable limitation of hip motion under codes 5250 thru 5253.  The orthopedic examination did not clearly address the left hip, while the NARSUM formal ROMs documented active flexion limited to 115 degrees with passive flexion to 125 degrees (normal) without specifying painful motion or mechanical limitation.  The Board adjudged that there was insufficient objective evidence of painful motion causing functional loss (based on §4.59, §4.40 and §4.45), and that the left pubic ramus fracture condition therefore warranted a 0% rating coded 5099-5003.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), for the right femoral neck grade IV stress fracture healing and left pubic rami stress fracture condition, the Board unanimously recommends an unfitting right hip with a disability rating of 10% coded 5299-5255, and by consensus, an unfitting left pelvic fracture with a disability rating of 0% coded 5099-5003.  

BOARD FINDINGS:  In the matter of the right femoral neck grade IV stress fracture healing and left pubic rami stress fracture condition, the Board unanimously recommends a finding of unfit for each condition with a disability rating of 10%, coded 5299-5255 for the right femoral neck stress fracture, and by a majority, recommends a disability rating of 0%, coded 5099-5003 for the left pubic ramus fracture condition; both IAW VASRD §4.71a.  The single voter for dissent recommended modification and did not elect to submit a minority opinion.  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	
Right Femoral Neck Grade IV Stress Fracture Healing	5299-5255	10%	
Left Pubic Rami Stress Fracture	5099-5003	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150530, w/atchs
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 XXXXXXXXXXXXXXXXXXXXX, AR20160018748 (PD201500540)

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