RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01578
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Food Inspection Trainee, medically separated for “chronic pain due to bilateral femoral stress fractures”  with a disability rating of 10%.  

CI CONTENTION:  She was given a higher rating for her conditions by the VA and continues to have pain that negatively impacts her daily activities.  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 - 20031210	VARD - 20050224	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Due to Bilateral Femoral Stress Fractures	5099-5003	10%	Residuals, Left Femur Stress Fracture	5099-5024	10%	20040324	
			Residuals, Right Femur Stress Fracture	5099-5024	10%	20040324	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Pain Due to Bilateral Femoral Stress Fractures.  The PEB combined the right and left femur stress fracture conditions under a single disability rating, analogously coded 5009-5003 and rated 10% with application of the US Army Physical Disability Agency pain policy.  This 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 noted that “bundling,” the combining of two or more major joints, may be 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.  The panel’s initial charge in this case was therefore directed at determining if 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 right and left femur stress fracture conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s hip condition began in July 2003 during basic training as left hip pain and without history of a specific injury.  On 21 August 2003, a bone scan revealed bilateral Grade I stress fractures of the proximal femurs and stress changes of the left second tarsal/metatarsal joint (foot), although the CI’s only complaint was left hip pain.  On 10 October 2003, bilateral hip X-rays revealed periosteal thickening of the proximal third medial aspect of both femora compatible with stress injury.  

During the 30 October 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported hip pain.  Physical examination noted full range of motion (ROM) and tenderness in the proximal femur area bilaterally.  The MEB NARSUM examination, on the same day, noted complaints of bilateral hip pain with symptoms unresolved with treatment.  The examiner referred to the DD Form 2808 for physical examination findings. 

The 24 March 2004 VA Compensation and Pension (C&P) general medical examination, 2 months after separation, recorded the CI as having normal posture and gait.  At the 26 March 2004 C&P joints evaluation, the CI reported pain over the proximal rectus femoris tendon at the hip level.  Walking more than half an hour caused severe pain and she took over-the-counter medication with only minimal relief.  There was no mention in the evaluation whether symptoms were bilateral or unilateral.  Physical examination showed bilateral hip flexion to 115 degrees (normal 125) and extension to -10 degrees (normal 20), without pain at ROM end points.  Bilateral external rotation was to 45 degrees (normal) and internal rotation to 30 degrees, without pain.  Repetitive passive motion did cause an increase in discomfort.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral femoral stress fracture condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing application of the US Army Physical Disability Agency pain policy.  The VA rated the left and right femoral stress fractures 10% each, both analogously coded 5099-5024 (tenosynovitis), based on the C&P examination 2 months after separation, citing painful or limited motion of a major joint.  The panel first considered if the right and left hip pain conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Members noted that the initial presentation was for left hip pain and that nearly all of the primary care and orthopedic notes, including the visit that recommended the MEB, were for left hip pain only, and that the right hip was rarely mentioned.  Although both hips (femurs) were implicated in the permanent profile and the commander’s statement based on bone scan findings, the clinical evidence was lacking to find the right hip separately unfitting; therefore, no additional disability rating is recommended.  The panel agreed that there was insufficient limitation of range of motion in the left hip to provide a minimum rating using VASRD codes 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of) or 5253 (thigh, impairment of).  In addition, there was no indication of a flail joint of the hip to support an 80% rating using code 5254, ankylosing of the hip to support a 60% rating using code 5250 or malunion of a femur fracture to support a 10% or higher rating using code 5255.  There was no evidence of painful motion (VASRD §4.59) to support a minimum rating due to painful motion of the left hip.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral femoral stress fracture condition.  

BOARD FINDINGS:  In the matter of the bilateral femoral stress fracture condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161012, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180001849, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					      
Enclosure