RECORD OF PROCEEDINGS
PHYSICAL DISABILITY   OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00546
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030522

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, basic trainee, medically separated for “stress fractures of superior and inferior pubic rami on right…stress reaction on left tibia” with a disability rating of 0%.

CI CONTENTION:  Right hip condition should be rated 30% to comport with the post-separation VA rating.   The CI’s 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 - 20030422	VARD - 20031006	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fractures of Superior and Inferior Pubic Rami on Right… Stress Reaction on Left Tibia	5099-5003	0%	Stress Fracture Right Superior Pubic Ramus	5299-5255	20%	20030819	
			…Stress Changes in Both Tibiae	5299-5284	0%	20030819	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Stress Fractures of Superior and Inferior Rami on Right and Stress Reaction on Left Tibia.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s stress fractures began in November 2002 without specific injury or trauma.  Treatment consisted of crutches and nonsteroidal anti-inflammatory drugs (NSAIDs).  X-rays on 22 January 2003 demonstrated radiolucency of the right inferior pubic ramus, possibly associated with a developing or healing stress fracture.  A 3 February 2003 bone scan was consistent with a healing stress fracture of the right superior and inferior pubic rami.  Diffuse stress changes were indicated from the knees to feet with more intense uptake in the bilateral mid tibiae, but did not appear to be stress fractures.  

During the 15 March 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported using crutches for the previous 2 months for fractured pelvis/pubic bone that was symptomatic on the right side.  The CI also noted treatment in January 2003 for falling down stairs with crutches.  The examiner documented inferior and superior pubic rami stress fractures.

The 22 March 2003 MEB NARSUM examination, 2 months before separation, noted CI complaints of chronic pain requiring the use of crutches for ambulation.  Physical examination showed markedly limited range of motion (ROM) of the right hip with flexion to 70 degrees (normal 125) and guarding.  Abduction was limited to 30 degrees (normal 45) due to guarding.  Extension was to +5 degrees and adduction was +10 degrees.   Internal and external rotation were painful at 5 degrees past neutral.  Internal rotation was to 15 degrees and external rotation to 60 degrees with painful motion from 30 degrees to 60 degrees.  (The NARSUM examiner reported right hip ROM twice.  It is speculation which hip was right and which was left, although presumably the initial measurements were of the right hip that had involvement of the superior and inferior rami and those that followed were of the left hip.)  The other ROM measurements, which were likely for the left hip, were flexion to 100 degrees, internal rotation to 20 degrees, external rotation to 70 degrees, abduction to 45 degrees, and extension to 20 degrees.   Knee ROM was full bilaterally and symmetric.  There was tenderness about the left medial tibia and with anterior-posterior compression testing of the pelvis.  No crepitus or gross deformity was noted.  

On 21 July 2003, bilateral hip radiographic studies demonstrated a suspected stress fracture with overlying bony margins of the right inferior pubic ramus.  Hip and sacroiliac joints as well as the symphysis pubic appeared intact.  X-rays of the knees on the same day demonstrated no significant abnormalities.  

At the 19 August 2003 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported continued pain.  Physical examination showed a normal gait.  There was a moderate degree of tenderness in the inguinal region bilaterally and over the pubis and both iliac crests.  Left hip flexion was to 105 degrees, abduction to 30 degrees and adduction to 20 degrees.  All hip movements were painful.  Left knee flexion was to 110 degrees (normal 140) and extension to 0 degrees (normal) without instability.  There was tenderness in the knees bilaterally over the patellar tendons.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled stress fractures of the superior and inferior rami on the right and stress reaction on the left tibia at 0%, analogously coded 5099-5003 (degenerative arthritis), citing healing confirmed with residual pain.  The VA rated the right pubic rami stress fracture 20%, coded 5299-5255 (femur impairment), based on the VA C&P evaluation 3 months after separation, citing continued residual moderate functional impairment.  The VA also rated stress fractures of the left calcaneus (not in the scope of review) with stress changes in both tibiae (the right tibia is not in the scope of review) 0%, coded 5299-5284 (foot injuries, other) citing only minimal functional impairment. 

Panel Approach to PEB Consolidated Rating. The PEB combined the bilateral stress fractures of superior and inferior rami on right and stress reaction on the left tibia conditions as a single unfitting condition coded 5099-5003 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, its recommendations may not produce a lower combined rating than that of the PEB, which is irrelevant in this case since the PEB rated the conditions together at 0%.  The evidence for the right superior and inferior rami stress fractures and the left tibia stress reaction was presented together above.  The profile addressed only the “right inferior pubic rami stress fracture,” while the NARSUM implicated both the “right inferior pubic ramus and superior pubic ramus stress fracture” and “stress reaction changes at the left proximal tibia.”  Members agreed that the stress fractures of the superior and inferior rami on the right condition were separately unfitting and the stress reaction on the left tibia was likewise separately unfitting. 

The panel first discussed rating options for the stress fractures of the right superior and inferior pubic rami.  There is no applicable code for fractures of the pubic rami, so members considered other rating options.  There was no limitation of flexion, extension or abduction that supported a rating under the VASRD diagnostic codes for limitation of motion (5251, 5252 or 5253).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no evidence of hip ankylosis or flail joint for a rating under codes 5250 or 5254 and there was no evidence of femur impairment to support a rating under code 5255 for femur impairment.  Panel members next discussed rating options for the left tibia.  The bone scan showed intense uptake in the left mid tibia, but no evidence of fracture.  Therefore, use of code 5299-5262 (tibia and fibula, impairment) is appropriate; however, the STR at the time of separation did not support a 10% rating for either slight knee or ankle disability. Thus, members determined that a 0% rating was applicable for the stress reaction of the left tibia.  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 stress fractures of superior and inferior rami on right condition, coded 5099-5003 and a disability rating of 0% for the stress reaction on the left tibia condition, coded 5299-5262. 

BOARD FINDINGS:  In the matter of the right stress fractures of the superior and inferior rami, the panel majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  In the matter of the stress reaction of the left tibia, the panel unanimously recommends a disability rating of 0%, coded 5299-5262 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Stress Fractures of Superior and Inferior Rami on Right	5099-5003	10%	
Stress Reaction on Left Tibia	5299-5262	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160908, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Minority Opinion.  The panel majority clearly noted the CI had painful motion of the hip, which warranted a 10% rating.  However, as noted in the panel discussion, the majority position was that the femur was never affected; therefore, use of code 5299-5255 was not applicable.  However, there is no applicable code for fractures of the pubic rami from a functional standpoint since the femur inserts into the acetabulum, which is part of the pelvis.  Likewise, the superior and inferior rami are part of the pelvis and hip motion is predicated on femur movement.  VASRD §4.20 (analogous ratings) states: “When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.”  Therefore, use of code 5299-5255 (femur impairment-malunion with hip disability) is not only applicable, but is appropriate, since there was no ratable limitation of motion for thigh limitation of extension, flexion, or impairment (codes 5251, 5252, and 5253).  More specifically, the CI had a malunion with at least moderate hip disability since despite physical therapy and medication, he was still using crutches 2 months before separation as noted in the NARSUM.  This was closer to separation than the VA C&P examination, 3 months post-separation, when crutches were reported to be no longer used.   Since healing was noted on a bone scan, the hip disability did not rise to a marked disability level at the time of separation.  However, because the CI still had a less than fully healed hip and was still using crutches within 2 months of separation, the minority voter strongly favors a 20% rating, coded 5299-5255, and recommends the ROP be modified as follows:

BOARD FINDINGS:  In the matter of the stress fractures of superior and inferior rami on right condition, the panel recommends a disability rating of 20%, coded 5299-5255 IAW VASRD §4.71a.  In the matter of the stress reaction on the left tibia condition, the panel unanimously recommends a disability rating of 0%, coded 5299-5262 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	
Stress Fractures of Superior and Inferior Rami on Right	5299-5255	20%	
Stress Reaction on Left Tibia	5299-5262	0%	
COMBINED	20%	

AR20170015812 , 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