RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2015-00640
BRANCH OF SERVICE: Army	SEPARATION DATE:  20020918

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Personnel Administration Specialist, medically separated for “trochanteric bursitis, left hip” and “chronic left wrist pain” as unfitting, rated 0% and 0% respectively, with a combined disability rating or 0%.  

CI CONTENTION:  The CI made no contentions.  The 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 - 20020626	VARD – 20021106	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Trochanteric Bursitis, Left Hip	5019	0%	Left Hip Bursitis	5251	0%	20020619	
Chronic Left Wrist Pain	5099-5003	0%	Left Carpal Tunnel Syndrome	8516	0%	20020619	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Trochanteric Bursitis, Left Hip.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left hip pain condition began in July 1997 after a motor vehicle accident and was treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy with improvement.  She had several recurrences between 1997 and 1999, which resolved with treatment.  However, left hip pain recurred and persisted and injections by pain management did not relieve the pain.  An orthopedic surgeon diagnosed the CI with left trochanteric bursitis with irritation of the left tensor fascia lata (fibrous tissue covering muscle) and the iliotibial band syndrome.  No surgery was recommended.  Magnetic resonance imaging (MRI) of the pelvis dated 31 October 2001 showed no evidence of left hip subluxation, instability or joint fluid.  Findings were compatible with mild left trochanteric bursitis, which could be secondary to repetitive irritation of the tensor fascia lata sliding over the greater trochanter and also could be seen with the snapping hip syndrome, associated with irritation by the iliotibial band.  An MRI of the lumbar spine was normal except for an anomalous right fifth transverse process and anomalous lower most ribs.  On examination in November 2001 the CI had tenderness of the trochanteric bursa with discomfort on full flexion of the left hip.  Despite treatment, the left 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 forwarded “trochanteric bursitis, left hip” for PEB adjudication.

At the MEB examination on 14 May 2002, 4 months prior to separation, the CI reported bursitis in the left hip.  On the clinical evaluation lower extremities were checked as abnormal without any details; however, trochanteric bursitis of the left hip was recorded in the summary of defects and diagnoses.  The NARSUM examination dated 14 May 2002 revealed tenderness to palpation of the left hip over the greater trochanteric bursa.  Discomfort was elicited on full abduction of the left hip.  Straight leg testing (to determine nerve root irritation) was negative.  The CI had a normal gait and good muscle strength of the lower extremity was noted without any neurological deficit.

At the VA Compensation and Pension (C&P) examination on 19 June 2002, performed 3 months before separation, the CI reported daily pain in the left hip.  Physical examination revealed a normal gait and a normal ROM of the left hip, which was not limited by pain, fatigue, weakness, lack of endurance or incoordination.  X-rays of the left hip were negative for acute fracture or dislocation.  

The range of motion (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.  

Left Hip (Thigh) ROM
(Degrees)	MEB ~4 Mo. Pre-Sep
	VA C&P ~3 Mo. Pre-Sep
	
Flexion (125 Normal)	FROM	125	
Extension (20)		30	
External Rotation (45)		60	
Abduction (0-45)		45	
Adduction (45)		25	
Comment	Discomfort on full abduction	ROM not limited by pain, fatigue, weakness, lack of endurance or incoordination	
§4.71a Rating	PEB 0%	VA 0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5019 code (Bursitis), citing trochanteric bursitis, left hip, without limitation of motion.  The VA also assigned a 0% rating using the 5251 code (thigh, limitation of extension of:) condition based on the VA C&P examination 3 months before  separation, citing findings were compatible with mild left trochanteric bursitis with a full ROM and was not limited by pain, fatigue, weakness, lack of endurance, or incoordination.

The Board majority determined there was evidence of painful motion based on the MEB examination where discomfort on full abduction was noted.  However, there was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of thigh extension, flexion or impairment (5251, 5252, or 5253).  The examinations proximate to separation did not demonstrate the presence of hip ankylosis (5250), hip flail joint (5254), or femur impairment (5255) to support a rating under the respective codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the trochanteric bursitis, left hip condition, coded 5019.  

Chronic Left Wrist Pain.  According to STR and the MEB NARSUM, the CI’s chronic left wrist pain condition began in June 1998 when she worked on a computer.  The diagnosis of extension tenosynovitis was made, which was treated with a splint and Motrin (ibuprofen, an NSAID).  She subsequently underwent aspiration of a recurrent ganglion four times, which failed to resolve the pain.  Thereafter, she underwent a carpal tunnel release and a ganglion cyst excision on her left wrist in November 2000.  Postoperatively, she complained of intermittent pain on the dorsum of her left wrist and occasional swelling at the site of the excision of the ganglion cyst and had decreased flexion of the wrist and intermittent tingling in December 2001.  On 4 February 2002 an electrodiagnostic study was interpreted as normal with no evidence of recurrent median nerve entrapment at the wrist.  

At the MEB examination the CI reported carpal tunnel left wrist and a history of the “left wrist broken 2 times (child).”  Physical examination revealed a scar of the left wrist.  The NARSUM examination dated 14 May 2002, revealed a full ROM of the left wrist and a well-healed incisional scar on the volar aspect of the left wrist.  Tinel’s sign (to determine median nerve irritation) was negative.  There was no muscle atrophy and the CI demonstrated a good grip and coordination.  

At the VA Compensation and Pension (C&P) examination on 19 June 2002, performed 3 months before separation, the CI reported weakness, pain and stiffness in the wrist.  Physical examination revealed a 4.5 cm x 1 cm scar on the ventral left wrist.  There was no tenderness, disfigurement, ulceration, tissue loss or keloid.  The general appearance of the wrist was within normal limits and the ROM was normal.  X-rays of the left wrist were negative for acute fracture or dislocation.  

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.  

Left Wrist ROM
(Degrees)	MEB ~4 Mo. Pre-Sep
	VA C&P ~3 Mo. Pre-Sep
	
Dorsiflexion (70 Normal)	FROM	70	
Palmar Flexion (80)		80	
Ulnar Deviation (45)		45	
Radial Deviation (20)		20	
Comment		AO	
§4.71a Rating	PEB 0%	VA 0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5099-5003 code (degenerative arthritis), citing chronic left wrist pain rated as slight/intermittent IAW USAPDA Policy/Guidance Memorandum #13.  The VA also assigned a 0% rating using the 8516 code (ulnar nerve paralysis of: ) based on the VA C&P examination 3 months before separation, citing negative Tinel and Phalen tests (to determine median nerve irritation) and a normal ROM of the left wrist with motion not limited by pain, fatigue, weakness, lack of endurance or incoordination.  There was no limitation of motion of the left wrist to support a rating under diagnostic code 5215 (wrist, limitation of motion of).  The MEB and VA C&P  examinations  did not note evidence of painful motion or other evidence of functional loss to support a 10% rating IAW VASRD §4.59, §4.40 or §4.45, and there was no ankylosis to justify a rating under the 5214 code (wrist, ankylosis of).  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 chronic left wrist pain condition.  

BOARD FINDINGS:  In the matter of the trochanteric bursitis, left hip condition, the Board majority recommends a disability rating of 10%, coded 5019 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  In the matter of the left wrist pain 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 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	
Trochanteric Bursitis, Left Hip	5019	10%	
Left Wrist Pain	5099-5003	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150605, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Minority Opinion.  The Board majority relied on the report that “discomfort was elicited on full abduction of the left hip” during the NARSUM examination on 14 May 2002, 4 months prior to separation, as its basis for determining a rating of 10%; however, discomfort is not defined in the VASRD and whether it is interchangeable or synonymous with the word pain in the setting of a physical examination on which a rating is to be determined is speculative.  Merriam-Webster Dictionary defines discomfort as “to make uncomfortable or uneasy.”  Furthermore, synonyms and related words do not include pain.  However, Google defines discomfort as “lack of physical comfort,” but does include “slight pain” as well as “a state of mental unease; worry or embarrassment,” while medicinenet.com defines pain as “an unpleasant sensation that can range from mild, localized discomfort to agony.”  Even if the definition of discomfort as slight pain were to be accepted, it fails to rise to the level required by VASRD §4.59 (Painful motion) states: “With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints.”  There was no report in the STR or VA examination of facial expression or wincing to indicate pain.  Furthermore, since there was no compensable limitation of motion, rating of code 5019 falls under code 5003 where “limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.”  As a matter of fact, the CI had discomfort on flexion during a prior examination in November 2001, also without any report of facial expression or wincing.  More importantly, at the NARSUM examination, the discomfort noted previously on flexion, 6 months earlier, was not noted or reported.  However, within 1 month of the NARSUM examination, there was neither discomfort on flexion or abduction at the VA examination where there was not only no note of discomfort, but there was no pain on motion with repetition.  Therefore, from a probative value standpoint, the VA examination was not only more proximate to separation, but it was also a more in depth examination with detailed reporting of each ROM of the left hip as well as noting the results of repetition IAW with DeLuca v. Brown as compared to the NARSUM examination where hip motion was noted to be a full range of motion without any goniometric measurements.  Furthermore, when the NARSUM examiner noted discomfort on abduction, he did not note whether it additionally limited the ROM, which since the November 2006 when the VA issued Fast Letter 06-25 requires at least three repetitions of the ROM.  It should be further noted that the CI had a normal gait at both the NARSUM and VA examinations.  Therefore, there was no evidence of painful motion proximate to separation with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45).  Furthermore, while VASRD §4.3 (Reasonable doubt) would seeming favor a 10% rating for the CI’s disability, VASRD §4.7 (Higher of two evaluations) does not, since the requirement that “the disability picture more nearly approximates the criteria required for that rating” had not achieved proximate to separation and in addition, VA §4.7 states “Otherwise, the lower rating will be assigned.”

Therefore, the minority voter recommends that the conclusion of the analysis be modified and adopted to read:  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 trochanteric bursitis, left hip condition.  

Additionally, the minority voter recommends the Board Findings be modified and adopted to read:  In the matter of the trochanteric bursitis, left hip condition and IAW VASRD §4.71a the Board recommends no change in the PEB adjudication.   The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

AR2017000438, XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and recommended that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s record of proceedings, majority recommendation and minority opinion (copy enclosed).  I regret to inform you that I reject the Board’s recommendation accept the minority opinion and your application to the DoD PDBR is denied.  There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.   

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,

Enclosure