RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00842
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040802

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 “pubic ramus and femoral neck stress fractures” and “stress reaction in right ankle,” with a disability rating of 0%.

CI CONTENTION: The CI contends she is “still experiencing pain and swelling due to my injuries from the service.”  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 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 - 20040628	VARD - 20041201	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pubic Ramus and Femoral Neck Stress Fractures and Stress Reaction in Right Ankle	5099-5022	0%	Right Inferior Pubic Ramus Stress Fracture	5299-5251	0%	20041004	
			Right Femoral and Tibial Neck Stress Fracture	5299-5260	0%	20041004	
			Left Femoral and Tibial Neck Stress Fracture	5299-5260	0%	20041004	
			Stress Fracture, Right Ankle	5299-5260	0%	20041004	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Pubic Ramus Condition.  The PEB combined the pubic ramus, bilateral femoral neck, and right ankle conditions as a single unfitting condition coded analogously to 5022 (periostitis) and rated 0%.  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 or implied adjudication that each condition was separately unfitting.  The diseases under diagnostic codes 5013 through 5024 are rated on limitation of motion of affected parts, as 5003 (arthritis, degenerative).  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 evidence for the pubic ramus, bilateral femoral neck, and right ankle conditions are presented separately, with attendant recommendations regarding separate unfitness and rating in the rating discussion.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the groin pain began while running during basic training.  An 18 February 2004 pelvis X-ray was normal.  A 20 March 2004 diagnostic imaging (bone scan) study showed a right inferior pubic ramus stress fracture (repetitive stress induced fracture).  A 9 April 2004 pelvis X-ray showed a right inferior pubic ramus stress fracture.  A 20 April 2004 bone scan showed a healing right inferior pubic ramus stress fracture.  The 23 April 2004 physical therapy (PT) examination revealed a normal gait and full active range of motion (ROM) of the bilateral hips.  On 24 May 2004, PT measured repetitive (X3) bilateral active hip ROM.  Right hip flexion was 112/112/113 (125 normal), extension was 15/15/17 (20), external rotation was 42/46/44 (45), abduction was 45/44/45 (45), and adduction was 25 (45) degrees.  Left hip flexion was 112/114/112 (125), extension was 12/12/12 (20), external rotation was 42/42/44 (45), abduction was 45/50/48 (45), and adduction was 22/25/25 (45) degrees.  

The 25 May 2004 NARSUM, 2 months before separation, recounted the history and interventions.  The CI complained of right groin pain that was 1/10 at rest and up to 6/10 with activity.  Symptoms were exacerbated by prolonged standing (> 15 minutes), walking (> 1 mile), running, stairs, and crawling and were relieved by resting and stretching.  The CI failed conservative management which included crutches, activity modification, and 30 days of convalescent leave, PT, and medications.  The focused examination revealed a non-antalgic (assuming a gait or posture to lessen pain) gait.  The examiner recorded “she ambulates freely without crutches.”  The pelvis examination revealed mild right inferior pubic ramus tenderness.  Strength, sensation, and pulses were normal.  The examiner recounted the findings of the X-rays, MRI, and bone scans.  The diagnosis listed right inferior pubic ramus stress fracture.  

The 4 October 2004 VA Compensation and Pension (C&P) examination, 2 months after separation, recounted the history and interventions.  The CI complained of bilateral 1/10 groin pain which began in basic training without a history of trauma.  Symptoms were exacerbated to 8/10 by prolonged sitting (> 30 minutes), prolonged standing (> 20 minutes), walking (> 10 minutes), and wet or cold weather and were relieved by rest, but not by medication.  The physical examination documented a normal posture and gait.  The bilateral hip examination revealed no point tenderness or evidence of spasm.  Right hip flexion was 120 (125), extension was 25 (20), external rotation was 30 (45), abduction was 45 (45), and adduction was 25 (45) degrees.  Left hip flexion was 130 (125), extension was 25 (20), external rotation was 50 (45), abduction was 45 (45), and adduction was 25 (45) degrees.  Limitations in ROM were secondary to pain.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of the X-rays, MRI, and bone scans.  The diagnosis listed bilateral hip pain likely due to bilateral femoral neck and right pubic ramus stress fractures which “appear to be healing by imaging studies.”

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether the pubic ramus condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating under an analogous 5022 code (periostitis) citing a pubic ramus stress fracture.  The VA assigned a 0% rating under an analogous 5251 code (thigh, limitation of extension of) based on the C&P examination, citing a right inferior pubic ramus stress fracture which appears to be healing and rated analogous to a disability in which not only the functions affected, but anatomical localization and symptoms, are closely related.  While the CI became symptomatic with physical stressors, subjective symptoms and objective examination and imaging findings improved/resolved when she desisted from the activity and rigors attendant to a military lifestyle.  There was no compensable thigh limitation of extension (5251), thigh limitation of flexion (5252), or thigh impairment of abduction, adduction, or rotation (5253) for consideration under the respective codes.  There was no hip ankylosis (5250), hip flail joint (5254), or femur fracture nonunion/malunion (5255) for consideration under the respective codes.  Board members agreed a 10% rating was not justified IAW §4.40 (functional loss) and §4.59 (painful motion).  The Board concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 0%, coded 5099-5022, is a good analogy to both the pathology and disability.  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 pubic ramus condition.  

Bilateral Femoral Neck Condition.  According to STRs and the MEB NARSUM, the bilateral hip pain began while running during basic training.  An 18 February 2004 pelvis X-ray was normal.  A 20 March 2004 bone scan showed possible bilateral femoral neck (subcapital compressive cortex) stress changes/reactions (precursor lesions to stress fractures).  A bilateral hip diagnostic imaging (MRI) study showed developing stress fractures in both femoral necks.  A 20 April 2004 bone scan showed uptake compatible with healing femoral neck stress fractures.  The 23 April 2004 PT examination revealed a normal gait and full active ROM of the bilateral hips.  On 24 May 2004 PT measured repetitive (X3) bilateral active hip ROM.  In the NARSUM the CI complained of sharp pain "between my hips" that was 1/10 at rest and up to 6/10 with activity.  Symptoms were exacerbated by prolonged standing, walking, running, stairs, and crawling and were relieved by resting and stretching.  The CI failed conservative management.  The focused examination revealed a non-antalgic gait.  The bilateral hip examination revealed mild right upper thigh tenderness with full ROM.  The log roll (assesses for hip joint pathology) and heel tap (assess for fracture or joint pathology) tests were negative.  Strength, sensation, and pulses were normal.  The examiner recounted the findings of the X-rays, MRI, and bone scans.  The diagnosis listed bilateral femoral neck stress fractures.  

In the C&P examination the CI complained of bilateral 1/10 hip pain which began in basic training without a history of trauma.  Symptoms were exacerbated to 8/10 by prolonged sitting, prolonged standing, walking, and wet or cold weather and were relieved by rest, but not by medication.  The physical examination documented a normal gait.  The bilateral hip examination revealed no point tenderness or evidence of spasm.  Right hip flexion was 120 (125), extension was 25 (20), external rotation was 30 (45), abduction was 45 (45), and adduction was 25 (45) degrees.  Left hip flexion was 130 (125), extension was 25 (20), external rotation was 50 (45), abduction was 45 (45), and adduction was 25 (45) degrees.  Limitations in ROM were secondary to pain.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings of the X-rays, MRI, and bone scans.  The diagnosis listed bilateral hip pain likely due to bilateral femoral neck and right pubic ramus stress fractures which appear to be healing by imaging studies.

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether the bilateral femoral neck conditions remain separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating under an analogous 5022 code (periostitis) citing femoral neck stress fractures.  The VA assigned a 0% rating for the left, and a 0% rating for the right, under an analogous 5260 code (leg, limitation of flexion of) based on the VA C&P examination citing left and right femoral neck stress fractures which appeared to be healing and rated analogous to a disability in which not only the functions affected, but anatomical localization and symptoms, are closely related.  While the CI became symptomatic with physical stressors, subjective symptoms and objective examination and imaging findings improved/resolved when she desisted from the activity and rigors attendant to a military lifestyle.  There was no compensable thigh limitation of extension (5251), thigh limitation of flexion (5252), or thigh impairment of abduction, adduction, or rotation (5253) for consideration under the respective codes.  There was no hip ankylosis (5250), hip flail joint (5254), or femur fracture nonunion/malunion (5255) for consideration under the respective codes.  Board members agreed a 10% rating was not justified IAW §4.40 (functional loss) and §4.59 (painful motion).  The Board concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 0%, coded 5099-5022, is a good analogy to both the pathology and disability.  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 bilateral femoral neck condition.  

Right Ankle Condition.  According to STRs and the MEB NARSUM, the right ankle pain began while running during basic training.  A 20 March 2004 bone scan showed bilateral ankle stress changes/reactions.  A 20 April 2004 bone scan showed diffuse bilateral ankle stress changes/reactions.  In the NARSUM the CI complained of and right ankle pain with any physical activity.  Symptoms were exacerbated by prolonged standing, walking, running, stairs, and crawling and were relieved by resting and stretching.  The CI failed conservative management.  The focused examination revealed a non-antalgic gait.  The right ankle revealed mild anterior tenderness, no swelling, no erythema (redness), and full ROM.  Strength, sensation, and pulses were normal.  The examiner recounted the findings of the bone scans.  The diagnosis listed right ankle pain and stress reaction (does not fail retention standards).  In the C&P examination the CI complained of bilateral 1/10 ankle pain and swelling which began in basic training without a history of trauma.  Symptoms were exacerbated to 6/10 by prolonged standing, walking, and wet or cold weather and were relieved by rest, but not by medication.  The physical examination documented a normal gait.  The right ankle examination revealed no gross deformity or abnormal varus or valgus angulation.  Right ankle dorsiflexion was 10 (20) and plantar flexion of 60 (45) degrees bilaterally without pain.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings of the bone scans.  The diagnosis listed ankle pain likely due to diffuse ankle stress reactive changes.  

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether the right ankle condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating under an analogous 5022 code (periostitis) citing right ankle stress reaction.  The VA assigned a 0% rating under an analogous 5271 code (ankle, limited motion of) based on the VA C&P examination citing diffuse right ankle stress reaction.  There was no compensable limitation of ankle motion (5271), ankle ankylosis (5270), subastragalar or tarsal joint ankylosis (5272), os calcis or astragalus malunion (5273), or excision of the astragalus (5274) for consideration under the respective codes.  Board members agreed a 10% rating was not justified IAW §4.40 (functional loss) and §4.59 (painful motion).  The Board concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 0%, coded 5099-5022, is a good analogy to both the pathology and disability.  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 ankle condition.  

BOARD FINDINGS:  In the matter of the combined pubic ramus, bilateral femoral neck, and right ankle 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 20150601, 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, AR20170001045 (PD201500842)

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