RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01739
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20071006

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, SATCOM Operator/Maintainer, medically separated for “bilateral hip pain” with a disability rating of 10%.  

CI CONTENTION:  Review of all conditions requested.  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 - 20070821	VARD - 20071121	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip Pain	5099-5003	10%	Left Hip Snapping Syndrome	5253	10%	20071004	
			Right Hip Snapping Syndrome	5253	10%	20071004	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Hip Pain.  The PEB combined the right and left hip conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 10% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  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 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 bilateral hip condition is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral hip condition began in March 2005 after increased exercising near the end of advanced training.  She was treated with medications and physical therapy and successfully deployed with her unit through fall of 2006.  During and following deployment, her bilateral hip pain increased.  Medications and conservative therapy did not adequately resolve the CI’s bilateral hip pain.   

The April 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, was signed by the same provider, and contained substantively the same information as the 24 May 2007 MEB NARSUM examination.  Both noted complaints of snapping hip syndrome.  Physical examination documented bilateral hip, inguinal ligament and greater trochanter tenderness.  There was no limitations of movement; however, there was pain at the end ranges of motion (ROM).  There was an audible popping sound heard with movement of the bilateral hips.  Bilateral lower extremity strength, reflexes and sensation were normal.

During the 27 July 2007 MEB NARSUM examination, 2 months prior to separation, the CI complained of snapping hip syndrome, with constant pain which increased with activities.  Physical examination revealed no muscle atrophy.  There was 4-5/5 strength bilaterally.  The active ROMs were left and right hip flexion to 80 degrees (normal 125) with left hip extension to 10 degrees and right hip extension to 5 degrees (normal 30); the CI could toe out to 40 degrees and cross the legs.  There was no mention of pain, although repetitions decreased some ROM; passive ROM was greater than active ROM.  Hip X-rays were negative and bone scan was normal.  

At the 4 October 2007 VA Compensation and Pension (C&P) examination, 2 days before separation, the CI reported snapping hip syndrome, with constant and increased pain with prolonged standing/sitting/inactivity; pain improved with activity.  The CI took tramadol every day with good relief, and Flexeril and Tylenol #3 for flares twice a month.  Physical examination showed a normal gait and posture.  There was bilateral hip tenderness.  ROMs were left and right hip flexion to 100 degrees and extension to 30 degrees with bilateral painful motion and no additional limitations on repetition.  The diagnosis was bilateral snapping hip syndrome.  

Directing attention to its recommendations, the panel first considered if the bilateral hip condition met the panel’s threshold for separate rating (as elaborated above).  The PEB bundled the right and left hip conditions and applied a single 10% rating coded analogously to 5003.  The VA separately rated the right and left hip conditions 10% each, coded 5253 (thigh, impairment), based on the C&P examination, citing reduced ROM with discomfort.  The commander’s statement and other STR evidence did not provide any information which would 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 hip would not have unacceptably interfered with the performance of military duties, members agreed that each hip was reasonably justified as separately unfitting.  

The panel then directed attention to its rating recommendation based on the above evidence. Both hips had similar symptoms and clinical findings, and therefore have the same rating considerations.  There was no compensable limitation of hip motion under codes 5250 thru 5253 for either the right or left side.  However, although the NARSUM ROMs did not specify painful motion, the MEB and pre-separation C&P examinations documented painful motion of each hip.  The panel adjudged that there was sufficient evidence of painful motion causing functional loss (based on §§4.59, 4.40 and 4.45), and that the right and left hip conditions therefore each warranted a 10% rating.  Analogous coding under 5003, 5253, or other codes using the 5003 criteria (5019 - bursitis; 5020 - synovitis; 5024 - tenosynovitis) were considered.  Given the negative diagnostic imaging and the 10% rating being principally based on VASRD §4.59, the panel adjudged that coding of 5099-5253 was predominant.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), for the right and left hip conditions, the panel recommends an unfitting right hip with a disability rating of 10% and an unfitting left hip with a disability rating of 10%, each coded 5099-5253.  

BOARD FINDINGS:  In the matter of the bilateral hip condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right hip condition, coded 5099-5253 and rated 10%, and an unfitting left hip condition, coded 5099-5253 and rated 10%, both 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	5099-5253	10%	
Right Hip Pain	5099-5253	10%	
COMBINED	20%	

AR20180014711 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.