RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00047
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20060912

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantryman, medically separated for “bilateral hip pain” with a disability rating of 10%.  

CI CONTENTION:  His left hip should also have been considered in the rating as well as a right knee meniscal tear, right shoulder strain, cervical strain, lumbar strain, and mood disorder.  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 MEB, but determined by the PEB 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 - 20060530	VARD - 20061215	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip Pain	5099-5003	10%	Left Acetabular Labrum Tear, Status Post Left Hip Arthroscopy	5299-5024	10%	20060829	
			Right Acetabular Labrum Tear, Status Post Right Hip Arthroscopy	5299-5024	10%	20060829	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Hip Pain.  The PEB combined the left hip pain and right hip pain conditions under a single disability rating, coded 5099-5003 (analogous to arthritis, degenerative) and rated 10%.  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 was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate ratings for bundled conditions, the panel considers each 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 left hip pain and right hip pain conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right hip arthroscopic debridement in September 2005 for a femoral acetabular impingement with labral tear.  The flap of articular cartilage was not debrided, as the surgeon opined that it would heal after the impingement was resolved.  When the CI had a return to full activity earlier than recommended by the surgeon, he almost immediately complained of a catching sensation with a pop causing pain.  In February 2006, he underwent a left hip arthroscopic debridement, again for a femoral acetabular impingement with labral tear, however he continued to complain of pain with activities post-surgery.  

During the 9 December 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported problems traversing over rough or uneven terrain and standing or walking for prolonged periods.  He also complained of difficulty sleeping due to hip pain.  Physical examination showed a normal gait and “decreased” range of motion (ROM) bilaterally in flexion, abduction, internal and external rotation with pain over the anterior joint.   

The 18 April 2006 MEB NARSUM examination, 7 months after the right hip operation and 5 months before separation, noted CI complaints of constant, dull pain in the right groin that worsened with standing in formation for more than 15 minutes, walking for more than 1 mile, running or jumping.  Intermittent left hip pain occurred 2-3 times per day lasting for 5-10 minutes, and was also elicited by lateral movement.  Physical examination of the bilateral hips was identical except that the right hip demonstrated an audible pop with flexion and extension as well as a positive FABER test (pain with flexion, abduction and external rotation of the hip).  ROM measurements showed flexion to 110 degrees (normal 125), extension to 25 degrees (normal 20), abduction to 45 degrees (normal) and internal rotation to 35 degrees (normal 40).  Painful motion was not addressed (other than in the FABER test).  

At the 29 August 2006 VA Compensation and Pension (C&P) evaluation, 2 weeks before separation, the CI reported constant, bilateral hip and groin pain that radiated to the lateral hip and down the leg.  Pain was increased with physical activity as well as lack of motion.   Nothing seemed to relieve the pain and he had difficulty getting into and out of a car, climbing stairs, walking and standing for longer than 30 minutes.  Physical examination showed normal posture and gait.  Right hip flexion was to 90 degrees and left hip flexion was normal.  The remainder of ROM measurements were equal bilaterally with extension to 30 degrees, adduction to 25 degrees (normal), abduction to 45 degrees, external rotation to 60 degrees (normal) and internal rotation to 40 degrees.  Pain was reported at the end of all movements with the exception of adduction and abduction.  Pain, fatigue, weakness and lack of endurance were reported bilaterally after repetitive motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB bundled and rated the right and left hip pain conditions 10%, coded 5099-5003 (analogous to arthritis, degenerative) citing no significant loss of ROM but chronic pain present.  The VA rated the right and left hip pain conditions 10% each, coded 5299-5024, (analogous to tenosynovitis), based on the C&P evaluation 2 weeks before separation, citing painful or limited motion of a major joint or group of minor joints.  
The panel first considered if the right and left hip conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both hips were considered to fail retention standards and were implicated by the profile, NARSUM and the commander’s statement.  Although the left hip appeared to be improving prior to separation, the commander’s statement and other STR evidence did not provide enough information to permit the panel to discriminate the performance limitations attributable to either hip over the other. Since undue speculation would be required to conclude that impairment from either would not have unacceptably interfered with duty performance, members agreed that each hip was reasonably justified as separately unfitting.  

Members agreed that there was insufficient limitation of range of motion in either 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.  However, there was evidence of painful motion with functional loss supporting a 10% rating in both hips (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 separate disability rating of 10% each, for the right and left hip pain conditions, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the right hip pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left hip pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 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	
Right Hip Pain	5099-5003	10%	
Left Hip Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160616, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180003279, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX: 

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