RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00203
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050404

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Basic Trainee, medically separated for “bilateral groin pain secondary to bilateral inferior pubic ramus stress fractures…” with a disability rating of 0%.  

CI CONTENTION:  The CI wrote a lengthy contention stating that her condition continues to bother her 11 years after service.  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 - 20050317	VARD - 20110712	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Groin Pain…Bilateral Pubic Ramus Stress Fracture	5099-5022	0%	Bilateral Inferior Pubic Ramus Stress Fracture	5099-5014	NSC*	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	
* Not Service Connected

ANALYSIS SUMMARY:  

Bilateral Groin Pain.  The PEB combined the left and right groin pain with pubic ramus stress fractures as a single unfitting condition coded 5099-5023 (analogous to periostitis) 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 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 evidence for the left groin pain with pubic ramus stress fracture and right groin pain with pubic ramus stress fracture are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral groin pain condition began in November 2004 after doing flutter kicks.  X-rays on the day of presentation, 23 November 2004, confirmed bilateral pubic ramus stress fractures.  She was treated with anti-inflammatory medications, physical therapy and rest including a 5 week period of convalescent leave without significant improvement.  

The 28 February 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of continued bilateral groin pain, left more than right that averaged 5 on a scale of 1 to 10 with 10 being the worst at rest and up to 7 with physical activity “when I do anything like lifting, marching and trying to run.”  Physical examination showed full range of motion of both hips with slightly painful motion on the left hip but not the right.  The examiner recorded, “her right side exam is totally normal.”  There was tenderness to palpation of the inferior pubic ramus on the left and tenderness with log roll (internally and externally rotating the hip with the hip and knee straight) and tenderness of the left hip with straight leg raising (flexion of the hip).  There was no VA Compensation and Pension (C&P) evaluation in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel first considered if the left and right groin pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel found that at the original presentation and at the majority of the medical visits following the complaint was bilateral groin pain, though the left was more severe than the right.  Panel members agreed the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended for each.  The PEB rated the bilateral groin pain and inferior pubic ramus stress fractures conditions 0%, coded 5099-5022 (analogous to periostitis), citing no significant loss of hip joint motion.  The VA did not initially service connect the bilateral inferior pubic ramus stress fracture condition coded 5099-5014 (analogous to osteomalacia), based on the STR, citing no permanent residual or chronic disability subject to service connection was shown by the service medical record or demonstrated by evidence following service.  

Left Groin Pain.  The panel agreed that there was insufficient limitation of range of motion of the left hip to provide a minimum rating using VASRD codes 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of) or 5253 (thigh, impairment of).  In addition, there was no indication of a flail joint of the hip to support an 80% rating using code 5254, ankylosing of the hip to support a 60% rating using code 5250 or malunion of a femur fracture to support a 10% or higher rating using code 5255.  The panel did find that there was sufficient evidence of painful motion (VASRD §4.59) to support a minimum 10% rating coded 5099-5022 due to the pain with motion.  

After due deliberation, the panel agreed that the preponderance of the evidence with regard to the functional impairment of the left groin pain condition favors its recommendation as a separately unfitting condition for disability rating.  It is appropriately coded 5099-5022 and meets the VASRD §4.71a criteria for a 10% rating.  

Right Groin Pain.  The panel established that there was insufficient limitation of range of motion of the right hip to provide a minimum rating using VASRD codes 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of) or 5253 (thigh, impairment of).  Additionally, there was no indication of a flail joint of the hip to support an 80% rating using code 5254, ankylosing of the hip to support a 60% rating using code 5250 or malunion of a femur fracture to support a 10% or higher rating using code 5255.  The panel did not find that there was sufficient evidence of painful motion (VASRD §4.59) to support a minimum rating due to the pain with motion.  

After due deliberation, the panel agreed that the preponderance of the evidence with regard to the functional impairment of the right groin pain condition favors its recommendation as a separately unfitting condition for disability rating.  It is appropriately coded 5099-5022 but does not meet the VASRD §4.71a criteria for a minimum rating.  

BOARD FINDINGS:  In the matter of the left groin pain with stress fracture of the pubic ramus condition, the panel unanimously recommends a disability rating of 10%, coded 5009-5022 IAW VASRD §4.71a.  In the matter of the right groin pain with stress fracture of the pubic ramus condition, the panel unanimously recommends a disability rating of 0%, coded 5009-5022 IAW VASRD §4.71a.  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	
Left Groin Pain with Pelvic Ramus Stress Fracture	5099-5022	10%	
Right Groin Pain with Pelvic Ramus Stress Fracture	5099-5022	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160411, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170014102, 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