RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01001
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E1 , Basic Trainee, medically separated for “bilateral hip pain” with a disability rating of 0%.  

CI CONTENTION:  No specific contention made.  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 Medical Evaluation Board (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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20061024	VARD - 20071031	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip Pain 	5099-5003	0%	Stress Fracture, Left Hip	5253	20%	20070207	
			Stress Fracture, Right Hip	5253	20%	20070207	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Bilateral Hip Pain.  The PEB combined the left and right hip conditions as a single unfitting condition analogously coded 5099-5003 (arthritis, degenerative) and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  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 also 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 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 right and left hip conditions is presented below with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s bilateral hip condition began in April 2006 at basic training during a road march.  The CI was treated conservatively with activity modification, anti-inflammatory medication, and physical therapy rehabilitation.  An MRI and bone scan showed inferior pubic rami fractures bilaterally.  Despite treatment, the CI continued to have pain with any type of movement, specifically marching, prolonged standing, or any type of aerobic event.  

The 15 September 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral hip pain.  Physical examination for range of motion (ROM) showed left hip flexion of 120 degrees (normal 125) with pain at extreme ROM, extension of 40 degrees (normal 20), external rotation of 60 degrees (normal 45) and abduction of 45 degrees (normal) without pain.  The ROM for the right hip was flexion of 120 degrees with pain at extreme ROM, extension of 40 degrees, external rotation of 60 degrees, and abduction of 45 degrees without pain.  A physical therapy examination the same day noted complaints of 4/10 bilateral hip pain.  Physical examination showed left hip flexion of 120 degrees, extension of 18 degrees, external rotation of 25 degrees and abduction of 55 degrees.  The ROM of the right hip showed flexion of 128 degrees, extension of 18 degrees, external rotation of 25 degrees, and abduction of 46 degrees.  

At the 7 February 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported constant bilateral pelvic pain.  Physical examination showed left hip ROM flexion of 110 degrees with pain, extension of 30 degrees, external rotation of 40 degrees with pain, and abduction of 30 degrees with pain throughout.  The ROM for the right hip was flexion of 110 degrees with pain, extension of 30 degrees, external rotation of 40 degrees with pain, and abduction of 30 degrees with pain throughout.  Gait was normal.  The examiner noted an additional 10-degree limitation following repetitive ROM due to increasing pain.  

The panel concluded there was not a preponderance of evidence in the service records that overcame the panel’s presumption that the bundled left and right hip conditions were reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting left and right hip conditions at the time of separation based on the above evidence.  The PEB rated the bilateral hip condition 0%, analogously coded 5099-5003, citing slight and intermittent pain IAW the USAPDA pain policy.  The VA rated each hip condition 20%, both coded 5253 (impairment of thigh), based on the C&P examination, citing loss of abduction of the thigh.  

There was no limitation of flexion, extension, abduction, adduction, or rotation that supported a rating under the VASRD diagnostic codes for limitation of motion (5251, 5252 or 5253).  There was no hip flail joint that supported a rating under VASRD diagnostic code 5254.  There was no impairment of the left or right 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 evidence of painful motion of the left and right hips with functional loss supporting a 10% rating for each (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 left hip condition and 10% for the right hip condition, both analogously coded 5099-5003.

BOARD FINDINGS:  In the matter of the left hip condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right hip condition, the panel 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Hip Pain	5099-5003	10%	
Right Hip Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007234, 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