RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01953
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050809

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Military Police, medically separated for “bilateral hip pain,” with a disability rating of 10%.

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 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 - 20050502	VARD - 20070220	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip Pain	5022	10%	Residuals, Bilateral Stress Fracture of the Hips	5299-5251	NSC	20060704	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Bilateral Hip Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral hip pain condition began in February 2004 after falling off an obstacle course at Basic Training.  She experienced pain and was evaluated.  Initial X-rays of both hips were read as normal but bone scan in July 2004 noted small and probably very early stress fractures involving the left more prominently than the right lateral femoral neck with mild generalized stress reactions in a component of both joints.  The MEB forwarded “bilateral hip stress reactions and femoral neck stress fractures, left greater than right” for PEB adjudication.  

The MEB NARSUM examination on 11 March 2005, 5 months prior to separation, noted complaints of bilateral hip pain.  She required the use of crutches to assist with walking and was unable to run, jump, march, perform sit-ups or push-ups, stand greater than 15 minutes or walk greater than 1/2 mile.  X-rays of the bilateral hips showed the bony structures, soft tissues and joints were normal but bone scan revealed mild interval improvement in the focal uptake previously seen in both lateral femoral necks with mild generalized increased uptake persistent in the bony portions of both hips.  A diagnosis of bilateral hip stress reactions and femoral neck stress fractures, left greater than right, were rendered.  Physical examination of the bilateral lower extremity showed no warmth or discoloration with tenderness over the greater hip bone bilaterally.   Flexion was limited to 110 degrees (normal 125 degrees) due to pain.  Range of motion (ROM) in internal rotation was limited by pain but external rotation was full with pain.  Motor and sensation were intact with 5/5 strength, with intact pulses bilaterally.  

An addendum one month on 7 April 2005 noted the CI had moderate pain and guarding of both hips for all planes measured with ROM of the right hip showing flexion 85 and abduction 35/35/35 and ROM of the left hip showing flexion 90 and abduction 25.  The Commander’s statement noted the CI was unable to take the Fitness Test (APFT) due to medical problems with her hips.  She was unable to perform her MOS related duties or basic soldiering skills due to her current medical condition.  

At the 4 July 2006 VA Compensation and Pension (C&P) Orthopedics evaluation, performed 11 months after separation, and as recorded by the VARD, the CI reported pain and weakness of the hip joints for which she took a narcotic medication as needed.  She reported she could not lie on her hip for an extended time.  X-rays showed age appropriate findings.  Physical examination showed gait was normal and ROM showed flexion to 120 degrees (normal 125 degrees) and extension to 10 degrees (20 degrees normal) bilaterally.  There was no medical evidence of bilateral chronic hip condition, although there was pain.  A diagnosis of chronic irritation of part of the left bursa was rendered.  

The PEB combined the left hip and right hip conditions as a single unfitting condition coded 5022    (periostitis) and rated 10%.  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 directed attention to its rating recommendation based on the above evidence.  As stated above, the PEB rated the bilateral hip pain condition 10%, coded 5022 (periostitis), citing moderate pain and guarding for all planes of range of motion.  The VA denied service-connection for the bilateral hip pain condition, citing current medical evidence which showed no chronic condition of the hips. The panel also noted that “bundling,” the combining of two or more major joints (in this case hips), is 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.  Under code 5003, when the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, a rating of 10% is applied for each such major joint or group of minor joints affected by limitation of motion.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  

In this case, the evidence of the service treatment record indicated both hips were equally symptomatic and individually were considered unfitting.  The commander’s statement and the profile implicated both hips.  The symptoms and physical examination findings were essentially the same in both hips, and the bone scan showed stress fractures bilaterally with greater involvement of the left hip than the right.  Both the MEB NARSUM and the Addendum exams showed evidence of pain on motion bilaterally, thus warranting a 10% disability rating (4.59) for each hip.  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 hip condition, coded 5022 and 10% disability rating of 10% for the right hip also coded 5022.  

BOARD FINDINGS:  In the matter of the bilateral hip pain condition, the panel unanimously or majority recommends a disability rating of 10%, coded 5022 IAW VASRD §4.71a for the right hip and a 10% disability rating of 10%, coded 5022 for the left hip.  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 Hip Pain	5022	10%	
Left Hip Pain	5022	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150713, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010008 , 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 20% 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