RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00748
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for a “left femoral neck stress fracture,” with a disability rating of 10%.

CI CONTENTION:  The CI contends activities aggravate the condition and prevent her from maintaining a steady job.  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 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 – 20061010	VARD – 20070614	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Due to Left Femoral Neck Stress Fracture	5099-5003	10%	Left Femoral Neck Stress Fracture	5255	NSC	20061207	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Pain Due to Left Femoral Stress Fracture.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had bilateral hip pain beginning in early 2006.  The right side pain spontaneously resolved, however, the left became progressively worse.  No specific injury or trauma was reported.  A bone scan on 28 March 2006 demonstrated bilateral femoral neck stress fractures and likely compensatory stress changes in the right knee, ankle, and foot.   X-rays of the left femur dated 28 March 2006 were normal.  Magnetic resonance imaging (MRI) of the hips on 31 March 2006 demonstrated Grade 3 stress fractures of the compressive side of both femoral necks, the left worse than the right.  Orthopedic evaluation on 31 March 2006 recommended continued crutch use and non-weight bearing on the left side.  At an orthopedic visit on 10 May 2006 the CI still continued to experience pain, but stated it was better than 6 weeks earlier, while at a 26 July 2006 visit, she reported the femoral stress fracture remained somewhat painful and a permanent profile was issued since she was unable to do any lower extremity activities or anything that would place a normal load on her hip.  Despite treatment, the pain due to left femoral stress fracture 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 “left femoral neck stress fracture, pain is marked and constant” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 26 July 2006 and 14 September 2006, 2-3 months prior to separation, the CI reported left hip pain and “not having full use of her left leg due to the femoral neck stress fractures.”  The examiner checked abnormal for lower extremities (except feet) for the clinical evaluation and noted the CI “ambulates well.  TTP [tender to palpation] left groin.  Without masses, nontender GT (greater trochanter), posterior hip, nontender with loading and stressing.  NVID [neurovascularly intact distally].  Motor and sensory grossly intact.  ROM [range of motion] flexion 90 degrees, external rotation 25 degrees, internal rotation 12 degrees, abduction 40 degrees, adduction 30 degrees.  Pain marked and constant.”  At the NARSUM examination dated 14 September 2006, 2 months prior to separation, the CI ambulated well.  There was tenderness on palpation of the left hip within the left groin and inguinal region without masses.  She was nontender to palpation over the greater trochanter, as well as the posterior aspect of her hip.  She had no tenderness with loading and stressing of the hip and she was neurovascularly intact distally with motor and sensory being grossly intact in all distributions.  ROM measurements were flexion at 90 degrees, external rotation at 25 degrees, internal rotation at 12 degrees, abduction at 40 degrees, and adduction at 35 degrees.  All were limited secondary to the CI’s complaint of pain.   The NARSUM examiner noted the CI demonstrated a propensity to develop stress reaction injuries while in military training and did not respond to profiling and nonoperative management for her femoral neck stress fracture.  The examiner concluded that it was unlikely that she would be able to resume training or service without reoccurrence or progression of her symptoms.  

At the VA Compensation and Pension (C&P) examination on 7 December 2006, performed 1 month after separation, the CI reported her condition was significantly improved.  She was able to walk on her own and took no medication.  On examination she walked with a normal gait.  Her hips were stable upon rocking with forced press and no pain was elicited.   The examiner’s diagnosis was “Reported left femoral neck stress fracture, now clinically resolved.”  The examiner then commented that the CI “apparently had stress fractures while in the military involving the left hip and possibly the knee and ankle.  The physical examination is entirely normal.  Range of motion is normal.  There are no areas of joint effusion, instability, reduced gait, or pain, or lack of coordination.”

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 Hip (Thigh) ROM
(Degrees)	MEB ~2 Mo. Pre-Sep
	VA C&P ~1 Mo. Post-Sep
	
Flexion (125 Normal)	90		
Extension (20)	-		
External Rotation (45)	25		
Abduction (0-45)	40		
Adduction (45)	35		
Comment	Motions limited secondary to complaint of pain	Hips were stable upon rocking with forced pressure; no pain elicited; physical examination normal; ROM normal	
§4.71a Rating	PEB 10%	VA NSC	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5099-5003 code (degenerative arthritis) for the left femoral neck stress fracture, citing the US Army Physical Disability Agency (USAPDA) pain policy.  The VA did not service-connect the condition under the 5255 code (Femur, impairment of :) for the left femoral neck stress fracture based on the VA C&P examination 1 month after separation, citing there was no permanent residual or chronic disability.  Board members considered an alternative rating since there was no hip ankylosis (5250), compensable thigh limitation of motion (5251, 5252, and 5253), or hip, flail joint (5254).  Therefore, use of code 5299-5255 since the CI had a femoral neck stress fracture, which by the time of separation, was not confirmed by an imaging study to have healed completely.  However, although there was nonunion, there was neither loose motion nor weight bearing preserved with aid of a brace.  Furthermore, there was no false joint.  However, although there was at least slight hip disability, a 10% rating with that code offers no benefit to the CI.  Members then considered whether there was moderate hip disability at the time of separation; however, while flexion was decreased at 90 degrees 2 months prior to separation, by 1 month after separation, the CI’s hips were stable upon rocking with forced pressure and no pain was elicited.  Furthermore, the CI reported taking no medication.  While the VA examination did not provide any ROM measurements for the left hip, the examiner concluded that the ROM was normal, although the VA examination included the back, shoulders, knees and ankles; therefore, the full ROM comment lacked specificity for the left hip per se.  Therefore, Board members felt the hip disability was not consistent with a moderate severity at the time of separation and a higher rating could not be justified.  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 pain due to femoral stress fracture condition.  

BOARD FINDINGS:  In the matter of the left femoral neck stress fracture 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 20150605, 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, AR20170002449  (PD201500748)

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