RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00991
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Infantryman, medically separated for “right acetabular inferior pubic ramus stress fracture and left proximal tibia stress fracture” with a disability rating of 0%.

CI CONTENTION:  The CI contends that his injury had healed incorrectly before he could get medical treatment, but is not interested in a disability rating.    The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’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 panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’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 panel 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 panel 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 - 20070914	VARD - None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Acetabular Inferior Pubic Ramus Stress Fracture and Left Proximal Tibia Stress Fracture	5099-5003	0%	 
 
No VA Examination in Evidence

COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:    

Right Hip.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hip condition began in February 2007 after navigating an obstacle course in basic training.  The CI was treated conservatively with rest and medications with improvement in the right hip pain at rest, but the CI reported continued pain with activity.  The MEB forwarded “right acetabular inferior pubic ramus stress fracture” for PEB adjudication.  

The permanent profile dated 12 July 2007 listed right pubic ramus stress fracture and left proximal tibial shaft stress fracture.  Physical limitations noted the CI could do upper body weight training, walk or bike at own pace or distance, with additional limitations of “unable to run, jump, or road march.”  The commander’s statement noted limitations due to “stress fracture left pelvis.”

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 11 July 2007, 3 months prior to separation, the CI reported problems due to the left leg fracture and the right pubic ramus fracture.  He was not using any medications but indicated he could not run, march, or carry a fighting load due to the fractures.  Physical exam noted only “tender R hip.”  The MEB examiner indicated a permanent L3 profile for the right pubic ramus fracture.  

The MEB NARSUM examination on 11 September 2007, 1 month prior to separation, noted complaints of hip pain.  Physical examination showed tenderness to palpation of the right inguinal area (over the pubic ramus bone).  There was no abnormality of the skin, warmth or deformity.  Physical therapy measured range of motion (ROM) for the MEB on 30 August 2007 and right hip ROM was flexion of 100 degrees (normal 125), extension of 10 degrees (normal 20) and abduction of 38 degrees (normal 45) and there was no limitation of motion that caused the CI to be unable to cross his legs or toe-out more than 15 degrees.  The therapist indicated limitation of motion was due to pain.  Plain films of the pubic ramus 26 April 2007 showed a healing stress fracture.  The MEB NARSUM examiner noted that the CI was able to walk without demonstrating pain, but stated that prolonged ambulation, standing, running, walking, road marching caused pain in both the right hip and left tibia.  The MEB NARSUM examiner determined the “right acetabular inferior pubic ramus stress fracture” was medically unacceptable and the CI failed to meet retention standards.  

There was no VA Compensation and Pension examination or other VA evidence in record.  To the panel’s knowledge, the CI never pursued disability benefits with the VA.  

The panel first considered if the right hip condition having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The commander’s statement erroneously implicated “left pelvis stress fracture” as impairing the CI’s duty performance.  The bone scan showed a left tibial stress fracture and stress fractures about the right hip.  The panel could not conclude from this if the commander was referring to the left tibial stress fracture or the right hip stress fractures.  However, the right hip condition was listed on the permanent profile and the MEB NARSUM examiner determined the CI fell below retention standards due to the right hip condition.  The panel concluded that there was not a preponderance of evidence of the service records that overcame the panel’s presumption that the bundled right hip condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right hip condition at the time of separation based on the above evidence.  

The PEB rated the combined right hip and left tibial stress fracture condition 0%, coded 5099-5003 (analogous to degenerative arthritis, citing the US Army Physical Disability Agency (USAPDA) pain policy.  

There was evidence at the MEB NARSUM exam of pain limited right hip ROM for a 10% rating for painful motion and functional loss (based on §4.59, §4.40 and §4.45).  There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh extension, flexion, or thigh impairment (5251, 5252, 5253).  There was no evidence of hip ankyloses, flail hip joint, or femur impairment (5250, 5254, 5255) for a rating under the respective codes.  There was therefore no higher rating than 10% available under any applicable VASRD §4.71a code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right hip condition, coded 5299-5252.  

Left Proximal Tibia Stress Fracture.  According to service treatment records (STR) and the Medical Evaluation panel (MEB) narrative summary (NARSUM), the CI’s left tibial stress fracture was noted on a bone scan in March 2007 during basic training.  The CI initially was being evaluated for complaint of right hip pain discussed above.  A bone scan in March 2007 showed a left tibial stress fracture that was “high grade” and a later imaging request noted that the bone scan had shown “intense uptake entire proximal tibia.”  At an orthopedic follow-up visit on 11 June 2007, the examiner noted that the CI had been placed in a cast for the left tibial stress fracture, followed by a brace and was much improved.  The exam noted “near” full range of motion of the left knee and tenderness in the vicinity of the tibial tuberosity.  Follow-up X-rays showed a healing non-displaced stress fracture of the upper tibial shaft.  At a primary care visit on 9 July 2007 the CI reported continued left leg pain after cast removal but reported the right hip was pain free, but he was unable to train due to the stress fractures.  The MEB forwarded “left proximal tibia stress fracture” for PEB adjudication.  

As noted above the permanent profile dated 12 July 2007 listed the left proximal tibial shaft stress fracture.  Physical limitations noted the CI could do upper body weight training, walk or bike at own pace or distance, with additional limitations of “unable to run, jump, or road march.”  The commander’s statement noted limitations of due to “stress fracture left pelvis.”

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 11 July 2007, 3 months prior to separation, the CI reported problems due to the left leg fracture and the right pubic ramus fracture.  He was not using any medications but indicated he could not run, march, or carry a fighting load due to the fractures.  Physical exam noted only “tender R hip.”  The MEB examiner indicated a permanent L3 profile for the stress fracture of the tibia.  

The MEB NARSUM examination on 11 September 2007, 1 month prior to separation, noted complaints of leg pain worsened by activity.  The exam noted that there had been improvement following leg casting and improvement with physical therapy but pain continued with activity.  Physical examination showed TTP over the proximal tibia.  The MEB NARSUM examiner noted that the CI was able to walk without demonstrating pain, but stated that prolonged ambulation, standing, running, walking, and road marching caused pain in both the right hip and left tibia.  The MEB NARSUM examiner determined the “left proximal tibial stress fracture” was medically unacceptable and the CI failed to meet retention standards.  

As noted above there is no VA evidence in record as the CI did not file a claim with the VA.  

The PEB combined the stress fractures of the right hip (inferior acetabulum and midline pubic ramus) and the left tibial stress fracture conditions as a single unfitting condition coded analogously to 5003 and rated 0% 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 panel 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 panel’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 panel 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 panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

The panel first considered if the left proximal tibia stress fracture condition having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  As noted above, the commander’s statement did not clearly implicate either or both of the stress fracture conditions.  However, the left tibial condition was listed on the permanent profile and the MEB NARSUM examiner determined the CI fell below retention standards due to the left tibial condition.  The panel concluded that there was not a preponderance of evidence of the service records that overcame the panel’s presumption that the bundled left tibial condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting left tibial condition at the time of separation based on the above evidence.  

There was no limitation of leg flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was insufficient evidence of painful, limited motion for 10% rating coded analogous to 5022 (based on §4.59, §4.40 and §4.45).  The panel next considered coding the tibial stress fracture analogously to 5262 (tibia/fibula impairment).  There was evidence of a high grade stress fracture with diffuse involvement of the entire proximal left tibia that required casting followed by use of a rigid knee brace.  The panel concluded that there was more likely than not some disability of the left knee secondary to the persistent tibial pain that warranted a 10% rating coded 5299-5262 for “slight” knee disability and no higher, based on the observation by the MEB NARSUM examiner that the CI was able to walk for a short time without demonstrating pain.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left tibial condition, coded 5299-5262.  

PANEL FINDINGS:  In the matter of the right acetabular inferior pubic ramus stress fracture and left proximal tibia stress fracture condition, the panel unanimously recommends a disability rating as follows an unfitting right acetabular inferior pubic ramus stress fracture, rated 10%, coded 5299-5252 and an unfitting left proximal tibia stress fracture rated 10%, coded 5299-5262, both IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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 Acetabular Inferior Pubic Ramus Stress Fracture	5299-5252	10%	
Left Proximal Tibia Stress Fracture	5299-5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150608, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007360 , XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found 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 recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure