RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00380
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20070520

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Motor Transport Operator, medically separated for “right hip stress fracture with bilateral knee pain due to stress fracture reaction and mild foot pain due to stress reaction,” with a disability rating of 0%.  

CI CONTENTION:  “Cannot sit or stand for long periods.  Cannot run or walk for a distance.  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 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 - 20070315	VARD - 20080313	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Hip Stress Fracture with Bilateral Knee Pain due to Stress Fracture Reaction and Mild Foot Pain due to Stress Reaction	5099-5003	0%	Stress Fracture of the Right Inferior Pubic Ramus Also Claimed as Right Hip Stress Fracture	5255	0%	20080215	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0% 	

ANALYSIS SUMMARY:  

Right Hip Stress Fracture with Bilateral Knee Pain due to Stress Fracture Reaction and Mild Foot Pain Due to Stress Reaction.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hip stress fracture with bilateral knee pain and mild foot pain condition began in 23 October 2005 during basic combat training when she developed pain in her right hip after running.  The CI was diagnosed with a right inferior pelvic region [ramus] (IFR) stress fracture based.  Bone scan studies showed decreased uptake consistent with disuse of the right leg and minor lesions at the right mid medial tibial and the medial tibial plateaus.  After convalescent leave on 28 November 2005, the CI continued to have pain with a severity of 7-8/10 with activity and weight bearing, but had no radicular symptoms, fever, or chills. On examination her right hip had an active full range of motion (ROM) and was stable.  Faber’s test (to determine hip pathology) was positive, scours test (to assess for non-specific hip pathology (femoral acetabular impingement or labral tears)) was +/-, and resisted hip adduction/extension was positive.  X-rays of the pelvis demonstrated a right IPR (stress fracture) with early callous without femoral neck periosteal change or lucency.  The CI had hip pain again after an Army PT test and was placed on crutches.  On 19 September 2006, bone scan ordered for an abnormal gait and a history of an old stress fracture of the right hip, demonstrated findings consistent with a stress fracture of the right inferior pubic ramus, stress changes of the knees and mid feet, and bilateral shin splints.  A laboratory test was negative for rheumatoid factor.  On 25 September 2006, an L3 profile for stress fractures was issued with the annotation “W/3 positive bone scans.”  During the 16 October 2006 MEB examination (recorded on DD Forms 2807-1 dated 27 September 2006 and 2808), 7 months prior to separation, the CI reported three stress fractures-pelvic, leg, hip.  The examiner noted multiple stress fractures to the hip/bilateral lower extremities.

The 5 January 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain all the time on the right hip especially when standing for 10 minutes, walking for 15 minutes, bending, lifting, crawling and climbing and she was awakened one to two times, five to six times a week.  Right hip flexion was 75 degrees (normal 125), abduction 45 degrees (normal 45), and adduction 25 degrees (normal 25) with pain at the end of motion. The Trendelenburg (to indicate an unstable hip due to weakness of the gluteus medius muscle), Faber (to determine hip pathology), and Thomas (to determine the tightness of primary hip flexor muscles) tests were positive.  Motor strength for right hip flexion was 4-/5, hip extension 5/5, hip abduction 4-/5 with weakness due to pain, and hip abduction 5/5.  Physical examination ROMs based on the NARSUM examiner’s measurements and physical therapy average measurements on 10 January 2007 showed right knee flexion was 139 degrees (normal 145) and left knee flexion 136 degrees and extension was 0 degrees for the right and left knees.  Active range of motion (ROM) was limited by soft tissue approximation and normal capsular movement.  Right ankle dorsiflexion was 10 degrees (normal 20) and plantar flexion 45 degrees (normal 45).  Left dorsiflexion was 5 degrees and plantar flexion was 42 degrees.  Right inversion was 31 degrees and left was 26 degrees; and right eversion was 21 degrees and left was 17 degrees with no limitation of pain.  The commander’s statement dated 20 February 2007 indicated the CI was physically incapable of reasonably performing her duties as a wheeled vehicle operator including assisting in ammunition loading/unloading due to her stress fractures.

At the 15 February 2008 VA Compensation and Pension (C&P) evaluation, 9 months after separation, the CI reported a stress fracture of the right hip, which occurred from repetitive activity, marked by weakness, stiffness, giving way, lack of endurance, and fatigability, all worse with activity.  The pain was relieved by rest and Tylenol (acetaminophen, a pain reliever).  The CI also reported being diagnosed with a right knee condition as a result of a twist injury with symptoms of swelling and locking, both worse with activity, which were relieved with rest and Tylenol.  The CI also reported being diagnosed with a left knee condition as a result of a twist injury without symptoms or pain.  She also reported being diagnosed with a stress fracture of the right inferior pubic ramus due to repetitive activity which was painful constantly and was relieved by bed rest and Tylenol.  Additionally, she reported being diagnosed with bilateral mid foot stress reactions due to repetitive activity.  She had no pain either at rest, while standing or walking and was not receiving any treatment.  Physical examination showed right hip tenderness without edema, effusion, weakness, redness, heat, guarding of movement and subluxation.  The right hip ROM was flexion 90 degrees, extension 20 degrees (normal 30 degrees), adduction 15 degrees, abduction 20 degrees, external rotation 60 degrees (normal 60), and internal rotation 40 (normal 40).  The hip was limited by pain after repetitive use.  Examination of the knee revealed no guarding of movement and no edema, effusion, weakness, tenderness, redness, heat, and subluxation. ROM measurements for both knees were 140 degrees flexion and 0 degrees extension.  There was no limitation of motion with repetition and there was no instability or meniscal impairment of either knee.  The ROMs of the right and left ankles were dorsiflexion 20 degrees and plantar flexion 45 degrees with no limitation of motion with repetition.  Examination of the both feet revealed no tenderness, painful motion, weakness, edema, atrophy or disturbed circulation.  Gait was within normal limits.  X-rays were not taken due to pregnancy.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right hip stress fracture with bilateral knee pain due to stress fracture reaction and mild foot pain due to stress reaction condition 0%, coded 5099-5022 (analogous to periostitis), citing bone scan and symptoms of pain.  The VA  also  rated the stress fracture of the right inferior pubic ramus also claimed as right hip stress fracture condition 0%, coded 5255, (femur, impairment of), based on the C&P examination 9 months after separation, citing “a noncompensable evaluation is assigned based on your in-service diagnosis of stress fracture.”

The PEB combined the right hip stress fracture with bilateral knee pain due to stress fracture reaction and mild foot pain due to stress reaction conditions as a single unfitting condition coded 5099-5022 and rated 0%. 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 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 right hip stress fracture with bilateral knee pain due to stress fracture reaction and mild foot pain due to stress reaction conditions was presented together above.  In this case, the CI’s primary complaint was related to the right hip stress fracture, while the bilateral knee pain and mild foot pain were identified on a bone scan.  Members agreed that the right hip condition is separately unfitting.  There was no limitation of extension or flexion sufficient enough to warrant a rating under those respective codes (5251 or 5252) or thigh impairment (5253) and there was no hip ankylosis (5250) or flail joint of the hip joint (5254).  Code 5299-5255 (femur impairment with malunion with slight knee or hip disability) at a 10% rating is reasonable since there is no distinct code for IPR, but the functionality is quite similar.  While the CI had tenderness, positive physical findings, and decreased flexion of the hip during the NARSUM examination, by the VA examination there was tenderness of the right hip and normal ROMs.  Therefore, members agreed the right hip condition did not rise to a moderate disability or warrant a 20% rating.  Members then discussed the bilateral knee pain, which was attributed to changes noted on bone scans in 2005 and 2006.  ROM measurements for the knees were within normal limits at the NARSUM and normal at the VA examination.  Although painful motion was not recorded; nevertheless, a rating using code 5099-5003 (analogous to arthritis, degenerative) at 10% is not unreasonable since there was bone scan evidence on two occasions of involvement of two or more major joints.  Members then discussed the mild foot pain.  While a bone scan demonstrated stress changes of the feet, ROM measurements of the ankles were within normal limits and no treatment other than medication was noted in the STR.  Furthermore, the CI had very limited complaints during service and no pain in the feet at the time of the VA examination.  Therefore, members discussed whether either foot alone or both feet were unfitting either separately or together.  Members concluded that since there was bone scan evidence of mild stress changes in the mid feet, albeit in the absence of any significant clinical findings including swelling, muscle spasm, or satisfactory evidence of painful motion, the condition would more likely than not be not unfitting.  However, both the profile and commander’s statement referred to bone scan findings and as a truck driver involved with loading and unloading a vehicle, having stress changes in the feet would limit her capabilities as a truck driver as well as loading heavy military materiel.  While use of code 5099-5003 could warrant a 10% rating based on imaging finding, they were not only not arthritic changes, but were mild stress changes.  Therefore, based on the totality of the findings and function of the feet, use of code 5284 is more applicable for the mild stress changes with a rating of 0% for each foot.  However, since there were imaging findings as well as the mild foot pain, the bilateral foot condition can be rated along with the bilateral knee pain since there were two or more joints as required by code 5003 at 10%, in the absence of any incapacitating episodes.

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 right hip pain condition, coded 5299-5255.  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 bilateral knee pain and mild foot pain conditions, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the right hip condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5255 IAW VASRD §4.71a.  In the matter of the bilateral knee pain and mild foot pain conditions, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 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	
Right Hip Pain	5299-5255	10%	
Bilateral Knee Pain and Mild Foot Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160705, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015446, 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