RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00632
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090925

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E2, Basic Trainee, medically separated for “stress fracture of the bilateral inferior pubic rami,” rated 10% for the right and 10% for the left, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The applicant makes no specific contention in her application.  The applicant’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 on 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 - 20090911	VARD - 20100129	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fractures of the Bilateral Inferior Pubic Rami 	5299-5255	10%	Right Hip, S/P Stress Fractures	5299-5255	0%	20091130	
	5299-5255	10%	Left Hip, S/P Stress Fractures	5299-5255	0%	20091130	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Stress Fractures of the Bilateral Inferior Pubic Rami.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s pelvic/hip pain condition began in May 2009 after her third week of basic training.  On 21 May 2009 the CI complained of left groin and right leg pain.  On examination there was tenderness on palpation of the left hip and pain with stress and extremes of motion.  Treatment consisted of Tylenol (acetaminophen, a pain reliever), calcium, and Vitamin D.  Radiographic (X-rays) of the left femur and right foot were normal.  Magnetic resonance imaging of the pelvis dated 29 May 2009 showed bilateral inferior pubic rami stress fractures with surrounding edema.  Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)) was added for pain control in June 2009.  An anterior posterior X-ray of the pelvis on 8 July 2009 showed a maturing left inferior pubic ramus stress fracture with robust callus formation and mild sclerosis at the site of the right inferior pubic ramus stress fracture without significant callus formation.  

At time of a physical therapy clinic appointment on 13 July 2009, the CI had full bilateral hip and knee range of motion (ROM), no tenderness over the bilateral greater trochanters and anterior hips, and negative testing bilaterally for hip pathology (Scour, FABER, and compression tests).  She did have pain at 6/10 with running.   Orthopedic evaluation on 21 July 2009 revealed tenderness on palpation on both sides of the pubic symphysis, but no tenderness on palpation of the hips.  Hip motion was normal and there was no pain or instability with hip motion. The hips showed no weakness and hip maneuvers were normal.  Because of continued pain, the CI was given a P3 profile.  Despite treatment, the bilateral hip pain condition 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 pelvic pain with bilateral pubic rami stress fractures” for PEB adjudication.

At the MEB examination (recorded on DD Form 2807-1 and 2808) dated 14 July 2009, 2 months prior to separation, the CI reported she was treated for hip fractures and had ongoing pain.  On examination the CI had painful ROM bilaterally of the lower extremities, left greater than right, (however, the hips were not explicitly addressed.)  The MEB NARSUM examiner noted on 5 August 2009, less than 2 months prior to separation, the CI continued to have chronic pelvic pain, which was constant in nature with a severity of 6/10 (10 being the worst pain).  With standing, walking, running and climbing stairs the pain might have reached as high as 9/10 in intensity.  ROM measurements are in the chart below.  There was no tenderness to palpation along the pelvic ring or the greater trochanters.  There was positive tenderness to palpation over the left inferior pubic ramus and along the left abductor muscles.  There was no tenderness to palpation with thigh squeezes bilaterally and no pain with external or internal rotation of the hips.  There was no clicking, mechanical locking or snapping of the hips with the ROM.  The CI walked with crutch ambulation; however, this was only for comfort, but when asked to walk without crutches, she had a normal gait.  The CI took ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID) for pain and had no improvement with physical therapy.  The examiner expected the CI to continue to have chronic pelvic pain for 6 to 9 months or maybe even up to a year and opined “the fractures will heal with time and the pain should resolve as the healing process completes.”  

At the 30 November 2009 VA Compensation and Pension (C&P) examination, performed 2 months after separation, the CI reported bilateral hip stress fractures in the service; her response to treatment was fair; and she took ibuprofen.  The examiner noted no lower extremity symptoms and no assistive aids for walking.  Physical revealed a normal gait and normal muscle strength. There was no joint swelling, effusion, tenderness, laxity, or ankylosis.  ROM measurements are in the chart below.

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Hips (Thigh) ROM
(Degrees)	PT ~2 Mos. Pre-Sep
	PT/MEB ~2 Mos. Pre-Sep
	VA C&P ~2 Mos. Post-Sep
	
	Left	Right	Left	Right	Left	Right	
Flexion (125 Normal)	“Full Bilateral Hip and Knee AROM”	100	120	95	100	
Extension (20)		10	10	30	30	
External Rotation (45)		-	-	-	-	
Abduction (0-45)		40	40	45	45	
Adduction (45)		-	-	-	-	
Comment	Negative testing for bilateral hip pathology	Pain at 90 flexion	No pain	Can toe in; can cross legs; no pain on motion; no limitation of motion on repetition	
§4.71a Rating	0%	0%	PEB 10%	PEB 10%	VA 0%	VA 0%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating (10% right and 10% left plus the bilateral factor), analogously coded 5255 (femur, impairment of), citing stress fractures of the bilateral inferior pubic rami causing hip pain with slight hip disability with consideration given for function loss IAW VASRD §4.10, §4.40, §4.45 and §4.59.  The VA rated the right hip and left hip both at 0%, analogously coded 5255 (femur, impairment of) based on the VA C&P examination 2 months after separation, citing right hip, s/p stress fractures, which was “non-compensable unless there is malunion of the femur with slight knee or hip disability.”   

Board members considered whether there was moderate hip disability of either or both hips sufficient to warrant a 20% for each hip.  However, members concluded there was insufficient evidence to support moderate hip disability prior to separation or after separation since the CI had a normal gait; and pain, if present, was controlled with ibuprofen; and tests of hip pathology were negative.  However, members noted decreased flexion, extension and abduction of the left hip, but not sufficient to warrant ratings under codes 5251 (thigh, limitation of extension), 5252 (thigh, limitation of flexion), and 5253 (thigh, impairment).  Furthermore, there was no ankylosis (code 5250) of either hip.  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 stress fractures of the bilateral inferior pubic rami condition.  

BOARD FINDINGS:  In the matter of the stress fracture of the bilateral inferior pubic rami 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 20150602, 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 XXXXXXXXXXXXXXXXXXXXX, AR20170000309 (PD201500632)

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