RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01608
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070827

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty, Chemical Operations Specialist, medically separated for “chronic right hip and leg pain” with a disability rating of 0%.  

CI CONTENTION:  Condition was not properly rated.  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 - 20070521	VARD - 20071029	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Hip And Leg Pain 	5022	0%	Chronic Right Hip and Leg Pain	5252	NSC	20070731	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Chronic Right Hip and Leg Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right hip and leg pain began in October 2005 during basic training.  Initial X-rays were negative, but bone scan in October 2005 showed stress changes of the femur.  Repeat bone scan in February 2006 showed stress changes of the femoral neck and lateral femoral condyle (femur at knee) and changes of the medial tibial plateau (tibia at knee) consistent with stress fractures.  An MRI of the right lower extremity performed in August 2006 did not show any stress fractures.  Another bone scan in September 2006 showed focal uptake of the right femoral neck and right lateral femur suggestive of early stress fractures.  

The commander’s statement dated 1 February 2007, noted stress fractures involving the right hip and leg impaired the CI’s successful performance of her duties due to physical limitations including the inability to move with a fighting load, construct a fighting position, run, perform sit-ups or push-ups, jump, bend or squat.  The permanent profile dated 25 April 2007 listed “chronic right hip and leg pain (stress fractures).”  

At the 11 January 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported hip and pelvis pain with prolonged standing that radiated to the knees.  Physical examination noted decreased ROM of the right hip and thigh due to pain in the pelvis and right hip.  There was tenderness of the right hip, inguinal area and the proximal femur.  Hip range of motion (ROM) was unable to be evaluated due to pain and the CI was also unable to heel and toe walk due to pain.  Hip X-rays performed on 17 January 2007 showed stress related changes of the proximal to mid femur.  

At the 17 January 2007 physical therapy ROM study, 7 months before separation, the CI was using a cane.  Right hip ROM (measured with a goniometer and repeated three times) was flexion of 38 degrees (normal 125), extension of 10 degrees (normal 30), abduction of 12 degrees (normal 45) and external rotation of 12 degrees (normal 60), with painful motion in all planes of  motion.  Knee ROM was flexion of 34 degrees (normal 140) and extension of 0 degrees (normal), with ROM limited by pain of the lateral knee.

The 7 February 2007 MEB orthopedic consultation noted complaints of right hip pain.  The CI reported groin pain radiating down the inner thigh since February 2006 with right knee pain that caused her to not want to bend it, but focused mostly on hip pain.  On physical examination, the examiner noted the CI was using a cane on the right side and was “somewhat” cooperative to examination, but was guarding and tearful during the examination due to pain.  Log rolling the hip reproduced her pain.  Hip ROM was noted as flexion of 100 degrees, full extension, abduction of 30 degrees and external rotation of 70 degrees, with painful motion.  There was tenderness to the greater trochanter.  The CI was “reluctant to flex and extend her knee,” but passive ROM was flexion of 135 degrees and extension of 0 degrees.  The orthopedic specialist’s assessment noted that other than “feared complaint” it was a “normal exam,” but noted the stress reaction of the right femur and determined the CI did not meet retention standards.  

The 5 March 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of chronic right hip and pelvic pain aggravated by weight bearing activity.  Physical examination showed a “slight limp” with use of a cane.  The MEB orthopedic consultation and PT MEB evaluation findings summarized above were cited.  The NARSUM determined the CI failed retention standards due to chronic right hip and leg pain secondary to chronic stress reactions in the right femoral neck and lateral femur.  

At the 31 July 2007 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported right hip and femur pain that radiated to the knee.  She reported weakness, a sensation that the knee wanted to give out and dislocation of the hip at times.  She denied stiffness, swelling, locking, lack of endurance or fatigability.  She reported at the time of pain she could function with medication.  Physical examination showed a normal gait and the CI did not “require an assistive device.”  There was tenderness and guarding of the right hip.  There was no swelling, weakness or subluxation.  Hip ROM was flexion of 125 degrees, extension of 30 degrees, abduction of 45 degrees and external rotation of 60 degrees, not additionally limited after repetitive use.  There was guarding of movement of the right knee without swelling, weakness or subluxation.  Knee ROM was flexion of 50 degrees and extension of 0 degrees with painful motion noted, but no additional limitation after repetitive use.  Right femur X-ray was normal.  

The panel considered whether the right hip and right leg condition, when considered separately, were unfitting.  The permanent profile listed “chronic right hip and leg pain (stress fractures).”  The commander’ statement noted stress fractures involving the right hip and leg impaired the CI’s successful performance of her duties due to her physical limitations as summarized above.  The MEB NARSUM indicated the CI failed retention standards due to chronic right hip and leg pain secondary to chronic stress reactions in the right femur.  In this case, the hip and leg pain were both consequences of the femoral stress reaction and were not distinct conditions which were separable for individual disability ratings.  The panel therefore deliberated a single rating for the unfitting chronic right hip and leg pain condition due to stress reaction.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right hip and leg condition at 0%, coded 5022 (periostitis), citing pain without significant loss of ROM.  The VA determined the chronic right hip and leg condition was not service-connected, citing no diagnosis of the hip or the leg at the pre-separation C&P examination.  

The VA examination, 1 month before separation, provided the panel the greatest probative value to the evidence at separation.  There was evidence of painful motion of the right knee at the VA examination to support a 10% rating coded analogously to 5255 (impairment of the femur).  Hip ROM was normal but the examiner did not address painful motion.  There was no limitation of extension or thigh impairment which supported a rating under the diagnostic codes for limitation of thigh flexion, extension or thigh impairment (5251, 5252, 5253).  There was no evidence of hip ankyloses, flail hip joint (5250, 5254) for a rating under the respective codes.  There was no evidence of additional knee impairment or separate diagnosis of the knee for consideration of rating under other VASRD knee codes.  There was therefore no higher rating than the 10% under any applicable VASRD §4.71a code.  The panel noted the PEB adjudication listed both hip and leg pain due to femoral stress reaction.  In this case the right femur stress reactions caused pain of the right hip and leg and pain related to a single diagnosis at two locations does not constitute separate conditions for which a rating may be assigned (IAW §4.14, avoidance of pyramiding).  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 right hip and leg condition, coded 5299-5255.  

BOARD FINDINGS:  In the matter of the right hip and leg condition, the panel recommends a disability rating of 10%, coded 5299-5255 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	
Chronic Right Hip and Leg Pain	5299-5255	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007956, 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