RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01684
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041113

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 “bilateral hip pain” with a disability rating of 0%.

CI CONTENTION:  The CI requested a review of 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 panel 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 - 20041004	VARD - 20050210	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip Pain…	5019	0%	Bilateral Hip Stress Fracture	5299-5254	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Hip Pain.  A The PEB combined the bilateral hip pain conditions as a single unfitting condition coded 5019 (Bursitis) 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.  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 bilateral hip pain conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral hip pain condition began in June 2004 during basic training with no specific trauma or injury.  Conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral hip stress fractures” for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 23 August 2004, 3 months prior to separation, the CI reported requiring the use of a cane.  Physical examination revealed hips with full range of motion, + tenderness bilateral trochanteric regions and bilateral inferior ischial regions.  Final findings of bilateral inferior pubic rami stress fractures.  The MEB NARSUM examination on 14 September 2004, 2 months prior to separation, noted complaints of bilateral hip pain since her third week of basic combat training.  Physical examination showed an antalgic gait requiring a cane for ambulation.  Bilateral hips with increased pain upon movement, positive left pelvic tilt test, and decreased range of motion in bilateral hips.  A 24 June 2004 bone scan revealed a focal uptake at the left IPR at the symphysis consistent with stress fracture.  Bilateral hip X-rays on 30 July 2004 including pelvis revealed acute stress fracture of the left inferior pubic ramus, question of mild stress fracture of the right inferior pubic ramus.  Final diagnosis was bilateral inferior pubic ramus stress fractures.  The CI did not show for her scheduled a VA Compensation and Pension (C&P) evaluation proximate to separation.  The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Right Hip (Thigh) ROM
(Degrees)	MEB ~3 Mo. Pre-Sep
	MEB ~2 Mo. Pre-Sep
	PT ~2 Mo. Pre-Sep
	
Flexion (125 Normal)	Full ROM	Decreased ROM	55/60/62	
Extension (20)	Full ROM	Decreased ROM	15/16/l5	
External Rotation (45)	Full ROM	Decreased ROM	30/35/33	
Abduction (0-45)	Full ROM	Decreased ROM	35/32/31	
Adduction (45)	Full ROM	Decreased ROM	32/30/33	
Comment	Painful motion	Painful motion	Painful motion	
§4.71a Rating	0%	0%	0%	

Left Hip (Thigh) ROM
(Degrees)	MEB ~3 Mo. Pre-Sep
	MEB ~2 Mo. Pre-Sep
	PT ~2 Mo. Pre-Sep
	
Flexion (125 Normal)	Full ROM	Decreased ROM	50/55/52	
Extension (20)	Full ROM	Decreased ROM	10/8/10	
External Rotation (45)	Full ROM	Decreased ROM	20/22/20	
Abduction (0-45)	Full ROM	Decreased ROM	10/12/14	
Adduction (45)	Full ROM	Decreased ROM	20/18/22	
Comment	Painful motion	Painful motion	Painful motion	
§4.71a Rating	0%	0%	0%	

The Board considered whether the right hip pain condition, when considered alone separate from the bilateral hip condition, was unfitting for continued military service.  The left hip was initially the source of pain but the CI’s condition progressed to affect both sides as evidenced by both hips showing stress fractures on X-ray and both the left and right had painful limitations of motion requiring the use of a cane.  Board members agreed that the evidence reasonably justified that the functional limitations of the right hip condition contributed to the CI’s inability to perform her MOS and accordingly a separate disability rating is recommended.
The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left hip pain with right hip pain and applied a single 0% rating coded 5019 (bursitis).  The VA rated the bilateral hip pain condition 0% coded analogously coded 5299-5254 (Hip, flail joint), based the STR, citing the STR and that the CI failed to report to a scheduled VA examination and absence of flail joint.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5251 or 5252).  There was no limitation of abduction or adduction or rotation that supported a rating under the VASRD diagnostic codes for limitation of motion (5253).  There was no hip flail joint that supported a rating under the VASRD diagnostic code (5254).  However, there was evidence of painful motion of the left hip with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 left hip pain condition, analogously coded 5299-5254 (Hip, flail joint).  

As noted above, the PEB bundled the left hip pain with right hip pain and applied a single 0% rating coded 5019 (bursitis).  The VA rated the bilateral hip pain condition 0% coded analogously coded 5299-5254 (Hip, flail joint), based the STR, citing the STR and that the CI failed to report to a scheduled VA examination and absence of flail joint.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5251 or 5252).  There was no limitation of abduction or adduction or rotation that supported a rating under the VASRD diagnostic codes for limitation of motion (5253).  There was no hip flail joint that supported a rating under the VASRD diagnostic code (5254).  However, there was evidence of painful motion of the right hip with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 right hip pain condition, analogously coded 5299-5254 (Hip, flail joint).  

BOARD FINDINGS:  In the matter of the left hip pain condition, the Board majority recommends a disability rating of 10%, coded analogously coded 5299-5254 IAW VASRD §4.71a.  In the matter of the right hip pain condition, the Board majority recommends a disability rating of 10%, coded analogously coded 5299-5254 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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	
Left hip pain	5299-5254	10%	
Right hip pain	5299-5254	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170003944, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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