RECORD OF PROCEEDINGS 
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00041
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090424

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aerospace Control & Warning System Craftsman, medically separated for “bilateral hip 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 conditions at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20090129	VARD - 20090520	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip Pain	5019-5003	10%	Bilateral Hip Disease Right	5252	NSC	20090305	
			Bilateral Hip Disease Left	5252			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Hip Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral hip condition began in June 2007 during a deployment.  The CI denied any specific injury or trauma.  On 1 November 2007 the CI complained of dull pain over the bilateral iliac crests, which was worse with pressure, but not associated with movement.  The hips had a full range of motion (ROM).  

On 1 February 2008 the CI reported pain in both of her hips which arose during temperature shifts from 50 degrees in cool storage to 100 degrees outside.  She noted the pain was located deep inside the hips with radiation of heat down the back of her legs to her calves.  She had a full ROM of the hips, but motion was painful.   Radiographic (X-ray) studies showed no evidence of any osteoarticular (joint) abnormality.  

Examination on 31 March 2008 noted tenderness on palpation of the inguinal ligaments and pain was elicited by hip motion.  Tests for hip dysplasia (Ortolani and Barlow’s) were negative.  An ultrasound study on 1 April 2008 of the pelvis revealed a 5.3 cm right ovarian cyst.  On 23 April 2008 the CI’s pain was thought be likely from tendonitis of the quadriceps insertion.  Restricted activity and physical therapy were recommended and Mobic (meloxicam, a nonsteroidal anti-inflammatory drug (NSAID)) was prescribed.  

Seronegative spondyloarthropathy (diseases of joints) was considered by a civilian rheumatologist as a cause of her hip pain and she was treated with medication including sulfasalazine (an anti-inflammatory sulfa drug).  A whole body scan on 23 May 2008 showed bone marrow expansion or arthritic changes in the large joints.  A military rheumatology evaluation indicated the CI’s pain was described as dull and pressure-like, which never resolved.  Prior magnetic resonance imaging (MRI) demonstrated both hips normal and a bone scan showed normal sacroiliac joint ratios with an “increased large joint uptake pattern.” Rheumatologic laboratory studies were normal (ANA, rheumatoid factor, HLA-B27, and sedimentation rate).  On examination the hips had full flexion, extension, external rotation, and slightly decreased internal rotation.  Ober’s test (to determine a tight, contracted or inflamed tensor fascia lata) was negative and the sacroiliac compression test and provocation test (Gaenslaen’s) were also negative, but there was tenderness to palpation of the trochanteric region bilaterally.  Steroid/anesthetic injections were given to the bilateral trochanteric bursae.  Despite the injections, pain persisted, but tenderness in the trochanteric regions decreased; nevertheless, no definitive diagnosis was made.  

On 17 September 2008 the CI stated that she had intermittent tingling numbness in the lateral thighs, which radiated to the lower legs and feet, but in no specific dermatomal pattern.  On examination there was no tenderness on palpation of the hips, which showed a full ROM without any hip pain or weakness.  The possibility of her pain being neurologic in origin was considered, but neurology evaluation was deferred pending an MEB.  

The 18 September 2008 MEB NARSUM examination, 7 months prior to separation, noted complaints of bilateral hip pain, which was initially mild.  She first sought care for the pain in February 2008 and thereafter underwent extensive evaluation by several specialists.  However, no cause of the pain was determined nor did treatment ameliorate her pain.  Physical examination showed no tenderness on palpation of the hips or bursa and no weakness in the hip flexors or extensors.  There was a full ROM of the hips with no worsening of the pain on motion.  There was no crepitus (grinding), no clicking, and no popping of the hips throughout movement.  Gait and stance were normal and neurologic evaluation revealed no upper or lower extremity weakness, no sensory deficits, and normal deep tendon reflexes.  On 25 November 2008 the CI had pain elicited by flexion and abduction of the hips.  Heel and toe walking was normal, but toe walking caused increased pain in the hip joints.  In December 2003 the CI had constant tingling and numbness in the back of her thighs and legs with walking, which was not responsive to Naprosyn (naproxen, an NSAID). Thereafter, Neurontin (gabapentin for nerve pain) was prescribed.  

The 21 January 2009 MEB NARSUM addendum, 3 months prior to separation, noted complaints of continued pain in the hips and pelvic girdle with a severity of 4-7/10 (10 being the worst pain) with slight relief with the use of Neurontin.  She had extreme discomfort with prolonged sitting and due to pain as well as aggravation by walking or lying still for prolonged periods.  On 22 January 2009 the CI had pain on active motion of the hips with bilateral hip tenderness and a full ROM.  

At the 5 March 2009 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported bilateral hip pain with sitting, lying down, standing and walking.  Physical examination showed no abnormalities of her posture or gait.  She had a full ROM of the back and the hips with minimal tenderness to palpation bilaterally in the anterior superior iliac spine areas, but nowhere else.  On 13 May 2009 the CI had tenderness on palpation of the greater trochanters and the gluteus medius muscles as well as other muscles of the upper torso. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral hip condition 10%, coded 5019-5003 (bursitis–degenerative arthritis).  The VA did not service connect either the left or right bilateral hip disease conditions, coded 5252 (thigh limitation of flexion), citing no chronic condition or permanent residuals for either hip.  

The PEB combined the bilateral hip pain conditions as a single unfitting condition coded 5019-5003 and rated 10%. The approach by the PEB commonly 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 separately unfitting.  The panel’s initial charge in this case was 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 Disability Evaluation System 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 evidence for the bilateral hip pain conditions was presented together above.  Members agreed that each hip condition is separately unfitting. 

Members noted that the CI had a full ROM of each hip on multiple examinations, therefore, use of codes 5251 (thigh, limitation of extension), 5252 (thigh, limitation of flexion), or 5253 (thigh, impairment of) do not offer a route to a higher rating nor did the CI have any hip ankylosis (code 5250), flail joint (code 5254), or femur or tibia impairment (codes 5255 and 5262).  However, the CI did have painful motion of the hips 3 months prior to separation, which would warrant a 10% rating using code 5099-5003 for each hip; however, painful motion was not present at the VA examination, 2 months prior to separation or at any of the other examinations proximate to separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral hip pain condition.  

BOARD FINDINGS:  In the matter of the bilateral hip condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160120, w/attachments
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-2016-00041.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings