RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00476
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20030907

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Network Switching Systems Operator, medically separated for “left hip pain” with a disability rating of 0%.  

CI CONTENTION:  “Misdiagnosis – see attached letter.”  The CI submitted a detailed letter outlining her 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 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 - 20030429	VARD - 20030918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left  Hip Pain	5009-5003	0%	Postoperative Residuals, Stress Fracture of Left Femoral Neck	5250-5024	10%	20030702	
	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Left Hip Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left hip pain condition began in September 2001 during basic training.  On 21 September 2001, the CI had a negative Patrick’s test (to determine hip pathology) and a full range of motion (ROM).  On 29 September 2001, she reported the left hip pain resolved, but had distal left thigh pain.  On 13 October 2001, she again complained of left hip pain.  On examination she had an antalgic gait and a full ROM of the hip.  There was increased tenderness of the proximal right femoral neck/hip with a positive Patrick’s test.  X-rays were negative.  Treatment consisted of Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)), crutches, and a profile.  A bone scan dated 18 October 2001 showed a mild focal lesion at the right proximal one third of the medial femur consistent with a mild stress fracture.  On 22 October 2001, physical therapy evaluation noted tenderness to palpation in the left groin, a positive scour’s test (to determine hip dysfunction) bilaterally, a negative Faber’s test (to determine hip pathology), a negative leg roll (to determine hip pathology), and a non-antalgic gait.  When the CI returned from convalescent leave, she was able to walk 40 minutes without pain.  On 9 January 2002, the CI reported she had no pain at all.  She had a full ROM, minimal tenderness at the left anterior hip, and was able to jump ten times without pain.  Later in January 2002 the CI was negative for all hip testing for hip pathology and she was cleared for Army physical fitness testing, if there were no pain with running.  On 27 February 2002, the CI reported pain recurred 2 weeks earlier with stretching and bending over as well as with sprinting and marching.  The examiner’s assessment was rule out a recurrent stress fracture.  Bone scan results noted on 3 April 2002 showed no evidence of a stress fracture.  On 22 May 2002, the CI reported significant improvement of the left hip and desired to take the PT test to EOC (end of cycle) and graduate.  The examiner noted the femoral neck stress fracture was determined to be resolved by magnetic resonance imaging (MRI) and bone scan.  On 10 September 2002, the CI reported pain with exercise and after riding a bicycle earlier in the day, the pain was worse.  On 15 October 2002, the CI still had persistent symptoms.  X-rays of the left hip on 19 June 2003 demonstrated no abnormality and an MRI of the hips on 28 June 2003 was normal.  

The 15 October 2002 MEB NARSUM examination, 11 months prior to separation, noted complaints of left hip pain.  Physical examination showed hip range of motion secondary to pain with approximately 30 degrees of flexion (normal 125), 10 degrees of internal rotation (normal 45), and 15 degrees of external rotation (normal 45).  The examiner noted that since the stress fracture was on the medial aspect of the femoral neck, no surgical options were indicated.  He opined that “Further increased use of her left hip may result in a complete femoral neck fracture with catastrophic long-term consequences.”  During 21 October 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 11 months prior to separation, the CI reported she had numbness in the lower legs following the initial stress fracture in the hip.  Physical examination showed painful ROM of the left hip with decreased ROM for hip flexion.

At the 22 July 2003 VA Compensation and Pension (C&P) evaluation, 6 weeks before separation, the CI reported daily pain in her left hip when aggravated such as when driving a car with a clutch.  Repetitive bending caused hip pain and she had to rest multiple times when climbing steps.  Physical examination showed a normal posture and gait.  The CI had decreased ROM secondary to pain and pain on motion.  Goniometer measurements were referred to the MEB.  Neurovascular status of the lower extremities were intact and the musculoskeletal strength was 5/5.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left hip pain condition 0%, coded 5099-5003 (analogous to arthritis, degenerative), citing there was “noted to be some limited hip ROMs secondary to pain” and “the bone scan noted medial stress fracture that a later MRI reported as healed.”  The VA rated the “postoperative residuals, stress fracture of left femoral neck” condition 10%, coded 5250-5024, (hip ankylosis-tenosynovitis), based on the C&P examination 6 weeks before separation, citing painful or limited motion of a major joint.  Members first noted that the PEB acknowledged “some limited hip ROMs secondary to pain,” which at minimum warrants at least a 10% rating IAW VSARD §4.59, §4.45, and §4.40 as well as DeLuca v. Brown.  Panel members also noted there was only one goniometric series of readings for rating purposes, which was reported in the MEB NARSUM where flexion was approximately 30 degrees.  At the VA examination more proximate to separation, the examiner referred to the MEB as the source for ROM measurements; nonetheless, the VA rated the CI not on limitation of motion per se, but for painful or limited motion of a major joint at 10%.  However, VASRD code 5252 (thigh, limitation of flexion) offers a 20% rating for flexion limited to 30 degrees.  Furthermore, the VA listed the CI’s disability as postoperative residual, stress fracture of the left femoral neck, but there was no surgery performed while on active duty.  There was no hip ankylosis (code 5250), thigh impairment (code 5253) or hip flail joint (code 5254) to provide a higher rating.  While there was femur impairment (code 5255), there was no fracture of the shaft or anatomical neck with nonunion, with loss motion or without loss motion, or weight bearing preserved with aid of a brace to warrant a higher rating.  While a stress fracture can be analogously coded 5299-5255, proximate to separation, both X-rays and an MRI indicated healing of the stress fracture.  Therefore, use of code 5299-5255 is not a viable option.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left hip pain condition, coded 5252.  

BOARD FINDINGS:  In the matter of the left hip pain condition, the panel unanimously recommends a disability rating of 20%, coded 5252 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 Hip Pain	5252	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160801, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015691, 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 and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,	
Enclosure