RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01291
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O2, Signal Officer, medically separated for “chronic bilateral hip pain,” with a disability rating of 0%.

CI CONTENTION:  His bilateral hip condition continues to worsen and negatively impact daily activities.  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 - 20060224	VARD - 20060804	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip Pain	5099-5003	0%	Greater Trochanteric Bursitis, Left Hip	5019	10%	20060511	
			Greater Trochanteric Bursitis, Right Hip	5019	10%	20060511	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Hip Pain.  The PEB combined the right and left hip conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative) 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 or implied adjudication that each condition was not separately unfitting.  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 right and left hip conditions is presented together, 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 CI’s bilateral hip pain began approximately 2 years prior to referral for an MEB.  Bilateral hip X-rays on 8 November 2005 were unremarkable and showed no gross fracture or dislocation.  A 15 November 2005 nuclear medicine bone scan showed no findings consistent with stress fractures about the hips.  In the 29 December 2005 orthopedic surgery MEB NARSUM, 4 months before separation, the CI complained of 18 months of bilateral hip pain without a history of an acute traumatic event.  The bilateral hip examination revealed no quadriceps atrophy.  Bilateral hip range of motion (ROM) was flexion of 110 (125 normal), abduction of 45 (45), external rotation of 45 (60) and internal rotation of 10 (40) degrees.  The Patrick (assesses hip and sacroiliac joint pathology) and straight leg raise [SLR] tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Strength, sensation, pulses, and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of the X-rays and bone scan.  The diagnosis listed bilateral hip arthralgia.  

During the 1 February 2006 family practice MEB NARSUM, 3 months before separation, the CI reported that he was "born with hip dysplasia [partial/complete hip joint dislocation at birth] and treated with a brace."  He complained of a gradual onset of bilateral hip pain in February or March of 2004 without any specific injury or trauma.  Also during this timeframe, while deployed to Iraq, he noted an increase in his bilateral hip pain.  The CI experienced an average 5/10 pain "75% to 80% of the time during the day."  The achy pain was lateral in the areas of the greater trochanters (proximal lateral femur bony prominences).  He denied radicular (nerve root irritation or injury) symptoms, paresthesias (abnormal sensation, tingling, burning, prickling), or pain causing awakening.  Symptoms were exacerbated by running (maximum of a quarter mile), standing beyond 20 minutes, and sit-ups; symptoms were relieved by rest.  In the physical examination section the author referenced the results written in the DD Form 2808 and the 29 December 2005 MEB orthopedic examination.  The author reiterated the examination findings of the X-rays, bone scan and orthopedic surgery MEB NARSUM.  The diagnosis listed bilateral hip arthralgia.  

During the 11 May 2006 VA Compensation and Pension (C&P) examination, 2 weeks after separation, the CI reported a history of congenital hip dysplasia and gradual onset of bilateral hip pain while in the service.  He complained of intermittent, daily, achy, 8/10 pain with associated fatigability and weakness.  Symptoms were exacerbated by sitting, prolonged standing more than 15 minutes and running; symptoms were relieved by a change in position and lying down.  The CI denied stiffness, swelling, heat, giving way, locking, flare ups, cane/crutch, or medication use.  The physical examination documented a normal gait with no assistive device used.  The bilateral hip examination revealed tenderness over the left greater trochanteric bursa (fluid filled sac between tissues [bones, muscles, tendons, skin]).  Right hip flexion, extension, abduction, and external rotation were normal; ROM for adduction was 20 (25), and internal rotation was 30 (40) degrees.  Left hip flexion, extension and abduction were normal; adduction ROM was 15 (25), external rotation was 30 (60), and internal rotation 30 (40) degrees.  The examiner also noted, “There would be some decrease in range bilaterally due to pain with repetitive use.  It is not possible to quantify the exact limitation in degrees.  No change in range due to fatigue, weakness or incoordination.”  Strength, sensation, and DTRs were normal.  The author recounted the findings of the X-rays and bone scan.  The diagnosis listed chronic bilateral hip pain most consistent with bilateral greater trochanteric bursitis (inflammation of bursa).

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each lower extremity condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating under an analogous 5003 code (arthritis, degenerative) citing chronic bilateral hip pain without a history of trauma. The PEB also noted that the CI was born with hip dysplasia treated with a brace, and had a normal bone scan, X-rays and ROM, and that the condition was rated for slight occasional pain.  The VA assigned a 20% rating under the 5019 code (bursitis) based on the C&P examination 2 weeks after separation, citing “chronic bilateral hip pain without history of trauma, most consistent with bilateral greater trochanteric bursitis, unremarkable bone scan and X-rays, ROM, and rated for painful or limited motion of a major joint or group of minor joints.”  There was no compensable thigh limitation of extension or flexion (5251 or 5252), or thigh impairment of abduction, adduction, or rotation (5253) for consideration under those respective codes.  There was no hip ankylosis (5250), flail joint (5254), or femur fracture nonunion/malunion (5255) for consideration under these respective codes.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §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 10%, coded 5099-5003, 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 recommends a disability rating of 10% for the bilateral hip condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bilateral hip condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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	
Chronic Bilateral Hip Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007916, XXXXXXXXXXXXXXXXXX

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Dear XXXXXXXXXXXXXXXXXX:

	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