RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02246
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20070215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Intelligence Specialist, medically separated for “pubic symphysis osteolysis with arthritis” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 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 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 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 - 20061205	VARD - 20070814	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pubic Symphysis Osteolysis with Arthritis	5299-5003	10%	Osteolysis with Arthritis of the Pubic  Symphysis with Musculoskeletal Strain on the Bilateral Hips 	5003	10%	20070530	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Pubic Symphysis Osteolysis with Arthritis.      

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s pubic symphysis pain/arthritis condition began gradually during boot camp in October 2004.  She subsequently had one pregnancy and one birth on January 19 2006 with exacerbation of her symptoms.  She had undergone an extensive workup including physical therapy, rehabilitation, activity modifications and GYN evaluation which was negative.  X-rays and a bone scan were negative for stress fractures or widening of the symphysis.  Further treatment did not result in improvement sufficient to allow unrestricted duty.  At the 2 October 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported chronic pubic symphysis pain.  Physical examination showed normal range of motion (ROM) of both hips.  Examiner noted pubic symphysis pain with abduction, internal, and external rotation of bilateral hips.  4+/5 strength with extension and flexion of the hips bilaterally.  4/5 strength abduction/adduction of legs bilaterally.  Normal sensation and reflexes.  The 3 October 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of being unable to run, jump, carry heavy weights, climb repeated stairs, or participate in martial arts, field duty, rifle range, or working parties due to her pelvis pain.  Physical examination of her sacroiliac joints had some mild tenderness, but no pain with lateral rotation or forward bending.  She had negative straight leg raise, negative cross leg raise.  She had no hip or groin pain.  She had full ROM of her hips, knees and ankles.  She had pain with positive lateral compression and distraction of her pubis symphysis and pain with palpation of the pubic symphysis.  At the 30 May 2007 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported that her pain worsened with weight bearing, hip flexion and when she rolls onto her side in bed and is often localized to the pubic region.  Physical examination showed bilateral inguinal region and tenderness on the lateral aspect of bilateral hips.  There was no warmth or swelling.  She had pain with palpation over her pubis and pain with attempted straight leg raise bilaterally.  Pain was elicited by passive flexion and extension of both hips.  Extension approximately 90 degrees bilaterally, with increased pain. ·External rotation 0-40 degrees (45 normal) with pain at 40 degrees.  Internal rotation was 0-30· degrees with pain at 30 degrees bilaterally.  She had bilateral hip pain by passive flexion at extreme range of motion.  Pain was also elicited by passive external rotation with the hip flexed.  There was no swelling of the hips.  

The PEB combined the pubic symphysis pain caused by bilateral hip motion conditions as a single unfitting condition analogously coded 5299-5003 (Arthritis, degenerative) 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 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 panel first considered if pubic symphysis pain directly related to the bilateral hip pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The MEB physical noted normal range of motion with pain noted in the pubic symphysis with adduction, internal and external rotation of the bilateral hips.  At the NARSUM examination the next day full range of the hips was noted with no painful motion.  There was some tenderness pubic symphysis area with movement of the pelvic bones.  At the C & P examination 7 months later the CI was again noted to have tenderness of the pubis symphysis area.  She was also noted to have some slight decreased ROMs with pain noted in each hip at the extremes of her ROM.  Per the STR notes proximal to her board date indicated that her hip pain was primarily manifested in her pubic region and resulted from the motion of both hips.  The MEB forwarded “pain in joint involving pelvic region and thigh” which implied that the hips were directly involved.  The panel majority agreed that the evidence reasonably justified that the functional limitations of each hip condition contributed to the CI’s inability to perform her military duties and accordingly a separate disability rating is recommended for each hip.  

The panel directed attention to its rating recommendation based on the above evidence.  As stated above, the PEB rated the pubic symphysis osteolysis with arthritis condition 10%, analogously coded 5299-5003 (Arthritis, degenerative).  The VA rated the osteolysis with arthritis of the pubic symphysis with musculoskeletal strain of the bilateral hips condition 10% coded 5003 (Arthritis, degenerative), based on the VA C&P examination 3 months after separation, citing evidence of arthritis of the pubis symphysis with a normal right hip x-ray and sclerotic change noted to the left hip.  For both hips 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).  There was evidence of painful motion of the hips with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) for each hip.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the right hip condition and 10% for the left hip condition.  

BOARD FINDINGS:  In the matter of the right hip condition, the panel majority recommends a disability rating of 10%, analogously coded 5299-5003 (Arthritis, degenerative).  IAW VASRD §4.59.  In the matter of the left hip condition, the panel majority recommends a disability rating of 10%, analogously coded 5299-5003 (Arthritis, degenerative).  IAW VASRD §4.59.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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	
Right hip condition	5299-5003	10%	
Left hip condition	5299-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150818, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 22 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(m) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(n) PDBR ltr dtd 21 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(o) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (o) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     g. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     h. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     i. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     j. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     k. XXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     l. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     m. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     n. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXXX
	Acting