RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00770
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20040526

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Trainee, medically separated for “bilateral femoral neck stress fractures” with a disability rating of 0%.

CI CONTENTION:  Current conditions support a higher rating.  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 - 20040513	VARD - 20041013	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Femoral Neck Stress Fractures…	5099-5003	0%	Residuals, Right Hip Femoral Neck Stress Fracture	5299-5255	20%	20040928	
			Residuals, Left Hip Femoral Neck Stress Fracture	5299-5255	20%	20040928	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Bilateral Femoral Neck Stress Fractures.  The PEB combined the bilateral femoral neck stress fractures conditions as a single unfitting condition analogously coded 5099-5003 (arthritis, degenerative) 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’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 bilateral femoral neck stress fracture conditions are presented together, 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 femoral neck stress fractures condition began in October 2003 with no specific trauma or injury.  The 22 April 2004 MEB NARSUM examination, 1 month prior to separation, noted complaints of pain which worsened with:  walking distances greater than 200 yards, running, jumping, and carrying greater than 10 pounds.  Physical examination showed bilateral hips range of motion (ROM) of flexion and extension to “120” degrees, abduction to 45 degrees (normal 45), adduction to 30 degrees (normal 45), external rotation to 45 degrees (normal 45).  There was no bilateral tenderness to palpation of the superior-inferior' pubic rami.

At the 28 September 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported persistent pain and lower back pain related to an altered gait.  Physical examination showed an abnormal gait.  There was marked tenderness, guarding, and discomfort on palpation of the sacroiliac region, and bilateral tenderness of the gluteals and over the greater trochanteric regions.  Right hip ROM was flexion to 105 degrees (normal 125), extension to 10 degrees (normal 20), abduction to 45 degrees, adduction to 25 degrees, and external rotation to 60 degrees (normal 45) with painful motion.  Left hip ROM was flexion to 110 degrees, extension to 10 degrees, abduction to 45 degrees, adduction to 25 degrees, and external rotation to 60 degrees with painful motion.  Repetitive ROM resulted in a marked increase in bilateral hip pain, but ROM remained unchanged.  There was bilateral fatigability and lack of endurance related to the pain.  No gross incoordination was noted bilaterally.  Deep tendon reflexes were normal with normal motor strength.  No gross instability was noted of either hip.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral femoral neck stress fractures condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing without significant loss of joint motion.  The VA rated the bilateral femoral neck stress fractures condition 20% for each hip, analogously coded 5299-5255, (femur impairment), based on the C&P examination 4 months after separation, citing painful motion.

The panel considered whether the right and left hip pain conditions, when considered alone separate from the bilateral femoral neck stress fracture conditions, was unfitting for continued military service.  The both hips showed stress fractures on bone scan and painful limitations of motion with increased physical activity.  Both hips were permanently profiled for no aerobic conditioning activities of running, biking, walking or swimming.  Panel members agreed that the evidence reasonably justified that the functional limitations of both the right and left femoral neck stress fracture conditions contributed to the CI’s inability to perform her military specialty and accordingly a separate disability ratings are recommended.

There was no limitation of flexion or extension of either hip that supported a rating under the VASRD diagnostic codes for limitation of motion (5251 or 5252).  There was no limitation of abduction or adduction or rotation of either hip that supported a rating under the VASRD diagnostic codes for limitation of motion (5253).  There was no hip flail joint that supported a rating under the VASRD diagnostic code (5254).  There was no impairment of either femur with fracture of shaft or anatomical neck with nonunion; or fracture of the surgical neck with a false joint; or malunion with slight knee or hip disability to justify a rating under 5255 (femur, impairment of).  However, there was STR and VA evidence of painful motion indicated in both right and left hips with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45).  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 femoral neck stress fracture condition and 10% for the left femoral neck stress fracture condition, coded 5299-5255.

BOARD FINDINGS:  In the matter of the bilateral femoral neck stress fracture condition, the panel unanimously recommends a disability rating of 10% for the right femoral neck stress fracture; and a 10% rating for the left femoral neck stress fracture, both coded 5299-5255 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 Femoral Neck Stress Fracture	5299-5255	10%	
Left Femoral Neck Stress Fracture	5299-5255	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160912, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170017587, 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