RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00905
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040616

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Ground Surveillance System Operator, medically separated for “persistent left hip and lower extremity pain” and “chronic low back pain,” rated at 10% each, with a combined disability rating of 20%.

CI CONTENTION:  “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 - 20040429	VARD - 20050628	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Persistent Left Hip and Lower Extremity Pain	5099-5003	10%	Left Hip Fracture (Fx)	5299-5255	20%	20040929	
			Left Hip Scar	7801	10%		
			Left Femur Fracture	5255	30%		
Chronic Lower Back Pain	5235	10%	Sacroiliac and Transverse Fx	5236	10%		
Intermittent/Left Foot Pain	Not Unfitting	Left Foot Fx 4th & 5th Metatarsals	5283	20%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Persistent Left Hip and Lower Extremity Pain.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left hip and lower extremity conditions began after being shot down in a helicopter on 2 November 2003.  Initial treatment consisted of an external fixator place for the hip fracture and a fasciotomy (opening up the covering around muscles, or fascia, to relieve pressure).  Evaluation on 8 November 2003 revealed a comminuted proximal femur fracture (thigh bone) and a left superior and inferior pubic ramus fracture (hip bones below the hip socket) with possible extension to the acetabulum (hip socket).  On 10 November 2003 he had an open reduction and fixation of the left femur with a rod and on 17 November 2003 he had internal fixation of both sacroiliac joint fractures with screws.  Postoperatively, he underwent physical and occupational therapy. 

X-rays of the pelvis dated 13 January 2004 demonstrated a comminuted left femoral neck fracture involving both trochanters (bones supporting the femur head) internally fixed with an intramedullary nail and compression screw.  Fractures of bilateral pubic and right ischial bones remained with minimal displacement.  At an orthopedic evaluation on 20 January 2004 the CI noted he had been performing full weight bearing since 29 December 2003.  Physical examination revealed a slight leg-length discrepancy with the left apparently less than the right.  Hip range of motion (ROM) was entirely normal and symmetric to the other side.  There was no discomfort to resisted hip flexion nor to percussion (tapping) of the femur up and down its length.  

A 27 January 2004 scanogram (X-ray to measure a structure) of the lower legs demonstrated a slight pelvic tilt with the right side higher than the left by 1.6 cm.  A leg length study dated 10 February 2004, ordered for a clinical examination that showed a 2.5 cm shortening on the left, also demonstrated a mild pelvic tilt, which gave about a 1.5 cm difference between the femurs, the left one appearing slightly longer.  All other measurements of the legs were essentially equal. The radiologist believed the finding was related to positioning and doubted any leg length discrepancy existed.  X-rays of the left hip showed post-surgical changes and the internally fixed left hip appeared to be in anatomical alignment.  For the shorter left extremity the CI was prescribed a lift in his shoe.  The 17 February 2004 commander’s statement indicated the CI had not been able to perform his daily duties since he suffered from fractures of the pelvis and left foot making it difficult for him to walk without assistance of a cane.

The 27 February 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of multiple fractures.  Physical examination showed a slight leg length discrepancy with the left less than the right.  Hip ROM was entirely normal.  There was no discomfort present to resisted hip flexion or to percussion of the femur up and down its length.  

During the 1 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported “femur fx causes permanent limp” and “shortened left leg.”  Physical examination showed scars of the left thigh and left iliac crest.  There was no tenderness of the left hip.  ROM measured in degrees showed left hip flexion was 123 (normal 125), abduction 40 (normal 45), and adduction 25.  Lower extremity measurements from ASIS (anterior superior iliac spine) to the medial malleolus on the left was normal.  

The 5 April 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of intermittent pain in the hip and femur provoked by running, standing and walking for more than 2 to 3 hours, riding in vehicles on bumpy roads, and any impact activities.  Physical examination showed no tenderness over either hip.  Hip flexion was 130 degrees on the right and 123 degrees on the left.  Abduction and adduction were unchanged from the March results.  The CI was issued a permanent L3 profile on 14 April 2004 for low back pain (LBP) after multiple fractures.

At the 29 September 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported a fracture of the proximal femur and acetabular fracture with arthritis and pain in the leg that flared up once a day for a few months at a time and limited walking.  Functional impairment was shortness of the left leg and he lost 3 months of work.  His posture and gait were normal.  He used no assistive devices.  Physical examination showed a scar on the left hip 32 x 2.5 cm.  Both legs were 100 cm in length and both hips appeared to have normal ROM.  There was no ankylosis or additional limitation based on pain, fatigue, weakness, lack of endurance, or incoordination.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left hip and lower extremity condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing degenerative arthritis and joint motion loss.  The VA rated the left hip condition 20%, analogously coded 5299-5255 (femur, impairment), based on the C&P examination 4 months after separation, citing painful and reduced ROM resulting in moderate hip disability.  The VA also rated the left femur condition 30%, coded 5255, citing marked left leg disability with shortened leg, painful and limited motion, and abnormal gait.

The PEB combined the persistent left hip and lower extremity pain conditions as a single unfitting condition coded 5099-5003 and rated 10%.  This 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 bilateral left hip and lower extremity (femur and acetabular socket) conditions was presented together.  Members agreed that because the anatomy and relationship of the hip joint, which includes the acetabulum and the femur, and the lower extremity that includes the femur, are not separately unfitting, that one rating for both conditions is not unreasonable and thereby avoids invoking VASRD §4.14 (avoidance of pyramiding).

The hip injury was the result of both the fracture of the femur and pelvis including the left superior and inferior pubic ramus fractures with possible extension to the acetabulum.  Therefore, while the initial injury was serious, after surgery and physical therapy and proximate to separation, the injury had improved somewhat.  VASRD code 5255 requires either nonunion of the fracture of shaft or anatomical neck, fracture of the surgical neck with false joint, or malunion with marked, moderate, or slight knee or hip disability.  While there was no nonunion as a result of the surgery, nevertheless, the use of the analogous code 5299-5255 offers a 20% option for moderate hip disability since there was shortening of the left lower extremity either as a result of the pelvic tilt or femoral fracture and repair.  Furthermore, the commander’s statement indicated the CI had not been able to perform his daily duties since he suffered from fractures of the pelvis and left foot making it difficult for him to walk without assistance of a cane.  However, the VA noted the CI had a normal gait, although he was rated for an abnormal gait.  In the absence of hip ankylosis (code 5250), thigh limitation of flexion (code 5252), thigh impairment (code 5253), hip flail joint (code 5254), or shortening of bones of the lower extremity more than 1¼ - 2 inches (code 5257) there was therefore no higher rating than 20% available under any applicable VASRD code. 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 persistent left hip and lower extremity pain condition, coded 5299-5255.

Chronic LBP.  According to the STR and MEB NARSUM, the CI’s chronic LBP condition also began in November 2003 after being shot down in a helicopter.  On 17 November 2003, he had internal fixation of both sacroiliac joint (joint in hip area that helps supports the spine) fractures with screws and intensive postoperative physical therapy.  X-rays on 13 January 2004 showed fixation of bilateral sacroiliac joint diastasis internally fixated with screws and a fracture of the left transverse process of L5.

During the 1 March 2004 MEB examination the CI checked ‘no’ to recurrent back pain or any back problem.  Physical examination showed tenderness of the left sacroiliac area and moderate dorsal kyphosis.  Forward flexion was 75 degrees (normal 90) with pain at 65 degrees with a combined ROM of 210 degrees (normal 240).  Motor strength was normal as was sensation except near scars.

The 5 April 2004 MEB NARSUM examination noted complaints of intermittent pain in the lower back provoked by running, standing and walking for more than 2 to 3 hours, riding in vehicles on bumpy roads, and any impact activities.  Physical examination showed tenderness to pressure over the left sacroiliac joint with radiation into the sciatic notch, but otherwise the lumbosacral spine area was without palpable spasm or tenderness to pressure.  Moderate dorsal kyphosis was noted but no tenderness to pressure or palpable spasm in the thoracic spine area.  Straight leg raising (to determine nerve root irritation) was negative except for complaints of pain in the left hip area.  Lumbosacral spine ROM was flexion to 75 degrees and combined ROM was 205 degrees with painful motion.  Neurologic evaluation was unremarkable other than decreased sensation near the injury and operative scars.  The examiner’s diagnosis was persistent LBP status post bilateral sacroiliac joint and L5 transverse process fractures, unresponsive to conservative treatment necessitating significant limitation of physical activity.

At the 29 September 2004 C&P evaluation the CI reported intermittent pain at the bottom of the spine twice a week lasting 2 hours at a time with physical activity; it was better with medicine.  There was no incapacitation, functional impairment or lost work time.  Physical examination showed no findings muscle spasm, tenderness, radiation of pain on movement, or abnormal straight leg raising.  ROM was flexion to 85 degrees and combined ROM was 225 degrees; painful motion was not addressed.  There was no additional limitation based on pain, fatigue, weakness, lack of endurance, or incoordination.  There was no ankylosis or intervertebral disc syndrome (IVDS).  X-rays dated 29 September 2004 revealed a normal curvature of the lumbar spine with unremarkable lumbar segments showing no recent or old injury.  There was no abnormality within the pedicles, facet joints or disc spaces.  At the sacroiliac joints there were screws extending through each joint in satisfactory position without evidence of fusion.  There was an old healed injury of the left superior and inferior pubic ramus where there was residual cortical deformity.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic LBP condition 10%, coded 5235 (vertebral fracture or dislocation), citing residual loss of motion and significant limitation of physical activities.  The VA rated the bilateral sacroiliac and transverse fractures condition 10%, coded 5236 (sacroiliac injury and weakness), based on the C&P examination 4 months after separation, citing injury of the spine with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) as reported on all examinations.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic LBP condition.

Contended PEB Condition:  Intermittent and Left Foot Pain S/P [status post] Multiple Metatarsal Fractures.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was implicated in the commander’s statement, but not profiled or judged to fail retention standards.  The CI sustained several left foot metatarsal fractures when the helicopter in which he was riding was shot down.  On 20 January 2004 he was noted to be ambulating with a special boot on his left foot.  Radiographs noted healing of his fractures and a residual fracture/dislocation of the left fifth metatarsal.  He continued with physical therapy and his foot healed well.  The 27 February 2004 MEB NARSUM examination noted resolved foot pain.  Physical examination showed some tenderness present initially at the third, fourth and fifth rays, but the CI was asymptomatic.  The 5 April 2004 MEB NARSUM noted weight-bearing X-rays of the left foot showed healing fractures.

At the 29 September 2004 C&P evaluation the CI reported he sustained fractures of the left fourth and fifth metatarsals with permanent dislocation.  He had pain standing, walking and at rest.  There was no functional impairment or lost work time.  Physical examination showed bilateral pes planus with no valgus or forefoot malalignment, no obvious limitation of function for standing and walking and no use of corrective shoe wear.

There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition; and so, no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the persistent left hip and lower extremity pain condition, the panel unanimously recommends a disability rating of 20%, coded 5299-5255 IAW VASRD §4.71a.  In the matter of the chronic LBP condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended intermittent and left foot pain s/p multiple metatarsal fractures condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Persistent Left Hip and Lower Extremity Pain	5299-5255	20%	
Chronic LBP	5235	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160919, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170018428, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure