RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01001
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040728

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Patriot Missile Crewmember, medically separated for “chronic pelvic and hip pain” with a disability rating of 0%.   

CI CONTENTION:  The CI made no specific 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 - 20040421	VARD - 20050322	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pelvic and Hip Pain secondary to Bilateral Inferior Pubic Rami Stress Fracture	5099-5003	0%	Fracture, Left Inferior Ramus	5299-5255	10%	20040722	
			Right Pelvic Stress Fracture	5299-5255	10%	20040722	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Pelvic and Hip Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s pelvic and hip conditions began during basic training around February or March 2002 without apparent trauma.  She began having pelvic, bilateral knee and bilateral ankle pains.  Bone scan showed multiple areas of focal uptake in the pelvis and lower extremities, consistent with stress fractures.  Lifting of a temporary profile allowed her to pass her physical training test.  She resumed running after the onset of active duty and in July 2002 had recurrent pain in the knees, ankles and pelvis.  She was placed on profile for 5 months with relief of her symptoms.  In January 2003 symptoms returned and she was placed on profile and transferred to Kuwait.  She resumed running in July 2003 with return of symptoms, relieved through personal physical training.  Recurrence occurred in February 2004 as training increased.  An ultrasound of her pelvis revealed pelvic fractures and she was referred again to Orthopedics.  There was no history of trauma.  

The 26 March 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of continued pelvic, bilateral knee, and bilateral ankles with weight bearing activities and long drives or standing.  She reported this restricted her ability to advance her physical training or perform daily duties as a soldier or have recreational activities.  Physical examination of the pelvis showed tenderness over the bilateral inferior pubic rami (lowest levels of the pelvis) with bilateral hip range of motion (ROM) testing recorded as 110 degrees flexion (125 normal), 15 degrees extension (20 normal), 25 degrees adduction (45 normal), 60 degrees abduction (normal), 80 degrees external rotation (45 normal), and 50 degrees internal rotation (45 normal).  Mild to moderate pain was noted at the pubic rami region with extremes of motion.  X-rays taken 5 March 2004 showed the bilateral fractures were stable.  She received a permanent profile for pelvic pain/stress fractures.  

At the 22 July 2004 VA Compensation and Pension (C&P) evaluation, 1 week before separation, the CI reported daily pain with a level of 2/10 worsening to 4/10 and worse with running and walking .  It was better with rest.  Physical examination showed an antalgic gait bilaterally due to ankle and foot pain.  Examination of the pelvis showed no tenderness in the pelvis or sacroiliac joints but there was tenderness in the groin areas bilaterally.  Hip flexion and extension worsened the pain.  There was mild tenderness in the iliac crest bilaterally.  Imaging did not reveal fractures or dislocations.  The examiner noted the pelvic pain was due to a fracture of the left ischial pubic bone and due to pelvic stress fractures.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the pelvic and hip pain 0%, coded 5003 (arthritis, degenerative (hypertrophic or osteoarthritis)), citing no significant loss of joint motion.  The VA rated the condition separately as right pelvic stress fracture, and fracture, left inferior ramus, at 10% and 10% each, both coded analogously to 5255, (femur, impairment of), based on the C&P examination 1 week before separation, citing pain with tenderness in the hip and iliac crest areas.

The panel also noted that “bundling,” the combining of two or more major joints (in this case bilateral inferior pubic rami, a part of the hip joint), is permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  Under code 5003, when the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, (5251, 5252, 5253) or ankylosis of the hip (5250), a rating of 10% is applied for each such major joint or group of minor joints affected by limitation of motion.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  
In this case, the evidence of the STR indicated both inferior pubic rami (hips) were equally symptomatic and individually were considered unfitting.  The MEB forwarded both inferior pubic rami stress fractures.  The symptoms and physical examination findings were essentially the same in both hips, and the bone scan showed inferior pubic rami fractures bilaterally.  

Using the information in the treatment record, the panel determined that the CI’s bilateral hip pain was essentially non compensable based on the VASRD §4.71a codes for loss of hip/thigh motion (5250 through 5253).  However; according to IAW VASRD §4.40, §4.45, and §4.59, a 10% rating is warranted when there is satisfactory evidence of functional limitation due to painful motion of a major joint.  In addition, the CI had an antalgic gait, which the examiner attributed to knee and ankle pain, but reasonably not distinguishable from hip pain.  Despite conservative therapy, hip and pelvic pain was recurring and limiting.  Both the MEB NARSUM and the C&P examinations showed evidence of pain on motion bilaterally, thus warranting a 10% disability rating (4.59) for each hip.  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 for the left hip condition, coded 5003 and 10% disability rating of 10% for the right hip also coded 5003.  

BOARD FINDINGS:  In the matter of the bilateral hip pain condition, the panel unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a for the right hip and a 10% disability rating of 10%, coded 5003 for the left hip.  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	
Pelvic and Right Hip Condition	5003	10%	
Left Hip Condition	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160920, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170017503, 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