RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01427
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090629

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Security Forces Journeyman, medically separated for “femoral anteversion [in-toeing] with chronic back and knee pain” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The 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 - 20090409	VARD - 20130429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Femoral Anteversion with Chronic Back and Knee Pain	5255	10%	Femoral Anteversion	8599-8526	NSC	STR	
			Back Condition	5237	NSC		
			Bilateral Hip Pain	5299-5252	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Femoral Anteversion with Chronic Back and Knee Pain.  The PEB combined the right and left femoral anteversion conditions under a single disability rating, coded 5255 (impairment of the femur, slight hip disability) rated 10%.  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’s initial charge in this case was therefore directed at determining if 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 adjudicated by the PEB.

According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral hip condition with chronic back and knee pain did not appear until after he joined the military.  He denied injuries to the hips or to either lower extremity.  He reported pain deep in the hip joint since joining the military.  The pain was not a problem until increased physical demands were placed on him.  He first sought medical intervention in October 2008 due to increasing pain in his hips.  He had a constant baseline level of pain, which became worse after exercise or during and after long periods of standing.  He was unable to pass the physical training test due to the increasing pain.  He had back and knee pain related to the hip pain.  Increased fitness requirements caused increasingly significant pain.  

He initially presented with an abnormal gait and noted pain with running.  He visited the emergency room due to back pain and was treated with muscle relaxants and anti-inflammatory medications.  Examinations showed no neurological deficits but the presence of paravertebral spasm.  Pain persisted and he was diagnosed with pes planus, referred to podiatry and given orthotics.  Orthopedics eventually diagnosed femoral anteversion, supported by neuroimaging of the hips, which showed right femoral anteversion with angle measuring 3 degrees and the angle on the left measuring one degree (adult normal is 15 degrees and symmetrical).  The military entrance processing examination, dated May 2006, did not show evidence of hip, back or knee problems.  X-rays showed normal lumbar spine.  The MEB forwarded “femoral anteversion (inward twisting of the thigh bone, also known as in-toeing) with associated lumbago and knee pain” for PEB adjudication.  He received a P2 profile and 24-hour quarters.

The 6 January 2009 MEB NARSUM examination, 6 months prior to separation, noted complaints of persisting pain that was treated with physical therapy, an anti-arthritis medication, a muscle relaxer and anti-spasm medication taken daily or as needed.  Physical examination showed no tenderness to either hip.  There was mild paraspinal tenderness and some spasm.  Hip, knee and ankle flexion/extension were normal.  External rotation of both hips was increased significantly:  CI could completely rotate right knee until facing backwards without pain.  Internal rotation was limited as CI could not walk with feet forward without pain.  The examiner opined the persistent back and knee pain, unresponsive to therapy, was due to the femoral anteversion.  The examiner noted he had been seen multiple times “for the natural sequellae of his congenital problem.”  He was unable to pass his annual physical testing.  The examiner opined the condition existed prior to service and was permanently aggravated by service (PSA).  He noted this problem would cause long- term arthritis and indicated excessive pain could result in surgical correction.  He received an L4 profile.  

The CI did not report for the VA Compensation and Pension (C&P) examination scheduled proximate to separation. The C&P examination conducted in 2014 was outside the range of probative value.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral femur condition 10%, coded 5255 (impairment of the femur, slight hip disability), citing “existed prior to service with service aggravation.”  The VA did not rate the bilateral femur condition until 2014, 5 years after separation, and then noted it was not service connected (NSC) due to absence of a VA examination.  The panel first considered if the bilateral femoral condition, having been de-coupled from the combined PEB adjudication, was separately unfitting.  A preponderance of the medical documentation depicted pain in both lower extremities that was unresponsive to therapy.  Members agreed, therefore, that the each lower extremity condition was reasonably justified as separately unfitting and that it met VASRD §4.71a criteria for separate rating. Accordingly, both the right and left femoral anteversion condition should be afforded a separate disability rating.  

The NARSUM examiner noted the back and knee pain were the result of the bilateral femoral anteversion.  In this case, the application of VASRD §4.14 (avoidance of pyramiding) does not allow separate ratings for the knees and the back.  The CI noted the pain began in both hips after joining the military.  He noted he had no signs and symptoms of any leg disorder prior to joining the military.  His primary care physician noted the CI did not complain of problems with his lower extremity nor was he diagnosed with any abnormalities in this area during the January 2004-August 2006 period under medical care, prior to entry into the service.  

The panel noted that femoral anteversion is usually diagnosed in early childhood, is not associated with pain and usually resolves on its own in childhood by age 10.  The CI denied pain in the hips prior to entry into the military.  On examination, the CI had significant loss of angulation, paravertebral spasm, could not walk without feet forward, was taking two medications daily and as needed for pain, and he would likely develop arthritis and possibly require surgery.  The CI was able to work in security forces but was unable to pass the fitness tests.  The persistent back and knee pain were unresponsive to therapy and the NARSUM examiner noted the condition was PSA.  The panel members agreed that although the condition usually was congenital and presented in childhood, the available evidence did not confirm a pre-existing condition and the disability for each extremity was more moderate than slight.  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 both the right and left femoral anteversion condition, with a combined rating of 20%, coded 5255.  

BOARD FINDINGS:  In the matter of the femoral anteversion condition, the panel unanimously recommends a disability rating of 20%, coded 5255 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Femoral Anteversion With Chronic Back and Knee Pain	5255	10%	
Right Femoral Anteversion With Chronic Back and Knee Pain	5255	10%	
COMBINED	20%	

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

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01427.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR