RECORD OF PROCEEDINGS
PHYSICAL DISABILITY PANEL OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01276
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Intelligence Collector, medically separated for “chronic bilateral hip and pelvic pain” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  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 review of disability ratings assigned 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 or non-compensable.  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 determination 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(s) 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 - 20040501	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Hip and Pelvic Pain…	5099-5003	0%	No VA Exam in Evidence	
Chronic Intermittent Low Back Pain (LBP)	Not Unfitting		
Bilateral High-Frequency Hearing Loss	Not Unfitting		
Myopia	Not Unfitting		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Bilateral Hip and Pelvic Pain. The PEB combined the bilateral hip and pelvic pain conditions as a single unfitting condition coded analogously to 5003 (degenerative arthritis) and rated 0%.  This 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 evidence for the bilateral hip and pelvic pain conditions are presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral hip and pelvis pain condition began in June 2002 during basic training, without acute or specific injury.  The CI reported left groin, hip, and buttock pain.  Radiographs showed a left pubic ramus fracture.  The CI continued to report pain, mainly in the groin on the left with activity.  In February 2003, bone scan studies showed “osteitis pubis” (overuse injury causing inflammation of the pubic symphysis where the two pubic bones join together) or possibly post-traumatic changes.  At the March 2003 orthopedic consult, the CI reported pain in the groin, mainly on the left.  In the spring of 2003 the CI noted some mild low back discomfort.  In July 2003, repeat bone scan showed persistent symmetric increased uptake in the area of the pubic symphysis.  In September 2003, STR indicated bilateral hip pain, left greater than right.  The CI’s bilateral hip and pelvic pain did not improve with conservative treatment and there was no surgical indication.  

The permanent profile dated 4 January 2004 listed chronic bilateral hip and pelvis pain.  The commander’s statement implicated bilateral hip and pelvic pain as impairing the CI’s successful performance of Army physical fitness testing and the duties of her military specialty.  

The 15 January 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, noted complaints of bilateral hip and pelvic pain and intermittent low back pain.  Physical examination showed no deformity or tenderness of the hips.  There was full range of motion (ROM) of the hips, with mild pain with flexion bilaterally.  Examination of the back showed no deformity or tenderness, full ROM, and negative straight leg testing (test for underlying herniated disk).  Bilateral hip X-rays in September 2003 were normal.  Left hip magnetic resonance imaging (MRI) in October 2003 was normal.  Lumbar spine X-rays in October 2003 were normal.  The NARSUM determined that the CI fell below retention standards due to bilateral hip and pelvic pain.

The 5 April 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain in the pelvis and groin area and some pain and stiffness in the low back.  Physical examination cited the hip and back findings of the DD Form 2808 examination above.  Physical therapy measured ROM for the MEB on 11 March 2004.  Back ROM was full flexion after three repetitions with combined ROM of 240 degrees (normal 240).  Left hip ROM was flexion 122 degrees (normal 125), extension was 40 degrees (normal 20), abduction 52 degrees (normal 45) and external rotation 42 degrees (normal 45).  Right hip ROM was flexion 120 degrees, extension 38 degrees, abduction 38 degrees, and external rotation 40 degrees.  

There was no VA examination in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic bilateral hip and pelvic pain condition 0%, coded 5099-5003 as indicated above, citing degenerative arthritis without loss of joint motion.  

The panel first considered if each of the right and left hip and pelvis conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The bilateral conditions were profiled and implicated in the commander’s statement and determined to fail retention standards.  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 and left hip and pelvic pain conditions were reasonably considered separately unfitting.  The panel also considered if the hip and pelvic pain condition could be further unbundled into hip pain and pelvic pain.  However, the identified pathology on the bone scan was osteitis pubis, an inflammation of the soft tissue connecting the right and left sides of the pelvis and the condition was associated with the CI’s right and left hip pain and intermittent low back pain, as well as left groin pain.  There was no separately identified pathology of the hips and the fitness implications of the hip and pelvic pain could not be separated from one another.  The panel then considered its rating recommendation for the unfitting right and left hip and pelvis pain conditions together at the time of separation.  

A bilateral 10% rating under the provisions of 5003 was considered, but it was concluded that the NARSUM provided satisfactory evidence for painful motion of both hips; thus, separate joint ratings were indicated IAW §4.71a.  There was evidence of limitation of hip ROM painful motion with functional loss supporting a 10% rating for each hip coded as 5099-5003 with bone scan findings analogous to degenerative arthritis; or coded as 5299-5252 (based on §4.59, §4.40 and §4.45) for painful flexion of the both hips noted at the MEB examinations.  There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh flexion, extension, or thigh impairment (5252, 5251, 5253).  There was no evidence of hip ankyloses, flail hip joint, or femur impairment (5250, 5254, 5255) for a rating under these respective codes.  There was therefore no route to a rating higher than the 10% for either hip under any applicable VASRD §4.71a code.  The panel noted that proximate to separation the CI also reported intermittent low back pain, but there were no objective abnormal findings of the back on imaging or at the MEB NARSUM examination.  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 and pelvic pain condition and 10% for the left hip and pelvic pain condition, both coded 5299-5252.  

Contended PEB Conditions:  Chronic Intermittent LBP, Bilateral High-Frequency Hearing Loss, and Myopia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic bilateral hip and pelvic condition, the panel unanimously recommends a disability rating as follows: an unfitting chronic right hip and pelvic pain condition, and an unfitting chronic left hip and pelvic pain condition, each rated 10%, both coded 5299-5252 IAW VASRD §4.71a.  

In the matter of the contended chronic intermittent low back pain, bilateral high-frequency hearing loss, and myopia conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are 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	
Chronic Right Hip And Pelvic Pain	5299-5252	10%	
Chronic Left Hip And Pelvic Pain	5299-5252	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150614, w/atchs
Exhibit B.  Service Treatment Record

AR20170008438, 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