RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01988
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E3, Trainee, medically separated for “right inferior pubic ramus stress fracture” and “degenerative arthritis L5-S1 and multi-level facet arthrosis,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  No specific contention was 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 - 20090311	VARD - 20110324	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Inferior Pubic Ramus Stress Fracture	5299-5255	10%	Right Pelvis Stress Fracture with Trochanteric Bursitis	5299-5255	10%	20100428	
Degenerative Arthritis L5-S1 and Multi-Level Facet Arthrosis	5242	10%	Lumbar Degenerative Disc Disease with Facet Arthrosis	5243	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Right Inferior Pubic Ramus Stress Fracture.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right hip condition began in July 2008.  X-rays dated 17 September 2008 demonstrated a right inferior pubic ramus stress fracture.  A bone scan dated 21 January 2009, ordered for persistent pain in the right inferior pubic ramus, showed a stress fracture of the right anterior pubic ramus and right acetabular focal stress changes.  Range of motion (ROM) measurements of the hip in the orthopedic clinic on 5 February 2009 were flexion 110 degrees (normal 125), extension 10 degrees (normal 20), and abduction 15 degrees (normal 45).  The CI was able to cross her legs and toe-out more than 15 degrees.  Pain interfered with weight bearing and standing.  She had extensive physical therapy, was on extended profiles, and took nonsteroidal anti-inflammatory drugs with no relief from pain.  

During the 5 February 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), one month prior to separation, the CI reported a fracture of the pubic bone.  Physical examination revealed right hip pain secondary to an inferior pubic ramus stress fracture.  Flexion was 110 degrees, extension 10 degrees, and abduction 45 degrees.  The same-day MEB NARSUM examination noted the complaint of right hip pain.  Physical examination showed a non-antalgic gait and was unremarkable for tenderness over the greater trochanter or posteriorly, although she had mild discomfort within the right groin.  There was no obvious quadriceps or hamstring atrophy.  She was able to cross her legs without difficulty and had out-toeing at approximately 55 degrees.  She had a negative Patrick’s test (to determine hip pathology).  ROM measurements were incorporated from the MEB examination with the addition of adduction of 35 degrees (normal 25).  Weight bearing X-rays of the hips dated 6 March 2009 were negative.  

At a VA primary care visit on 30 December 2009, 9 months after separation, the CI complained of status post stress fracture of the right hip.  Examination of the right hip was not recorded.  At a VA orthopedic clinic visit on 22 March 2010, 12 months after separation, the CI reported a history of stress fracture of the right hip.  Examination revealed tenderness over the symphysis pubis and pubic rami.  She also had tight quadriceps and weak hip abductors, extensors and flexors.  X-rays of the right hip were normal and showed no specific bone and joint abnormalities. 

At the 28 April 2010 VA Compensation and Pension (C&P) examination, 13 months after separation, the CI reported pelvic pain.  Physical examination showed right hip tenderness.  ROM measurements were flexion 0-100 degrees, abduction 0-35 degrees, extension 0-20 degrees and external rotation 0-45 degrees (normal 45), all with pain.  X-rays for bone length of the lower extremities on 23 May 2010 showed the left lower extremity was 0.45 cm longer than the right lower extremity.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the hip condition 10%, analogously coded 5299-5255 (femur, malunion), citing VASRD §§4.10, 4.40, 4.45 and 4.59 and slight hip disability.  The VA also rated the hip condition 10%, analogously coded 5299-5255, based on the C&P examination, citing slight limitation of motion and painful movement of the hip.  

The panel noted there was no evidence of hip ankylosis (code 5250), thigh limitation of flexion (code 5252), thigh impairment (code 5253), hip flail joint (code 5254), or femur impairment malunion with moderate hip disability (code 5255), since weight bearing X-rays of the hips were normal one month prior to and at 12 months after separation, to warrant a higher rating than the 10% as assigned by the PEB at the time of separation.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right inferior pubic ramus condition.  

Degenerative Arthritis L5-S1 and Multi-Level Facet Arthrosis.  According to the STR and MEB NARSUM, the CI’s back condition began in October 2008 after falling down a flight of stairs.  She experienced occasional bilateral lower extremity tingling sensations, but denied saddle dysesthesia or changes in bowel and bladder habits.  X-rays of the lumbar spine dated 13 January 2009 showed minimal endplate irregularity at the inferior aspect of T12, but was otherwise normal.  An MRI on the same day demonstrated moderate degenerative disc changes at L5-S1 with facet arthrosis at L3-L4, L4-L5, and L5-S1 but without neural impingement.  

During the MEB examination, the CI reported a bulging/herniated disk in the spine, which caused pain. Physical examination revealed tenderness over the T7-T8 and L5-S1 spinous processes.  The MEB NARSUM examination noted the complaint of low back pain with occasional bilateral lower extremity tingling sensation without saddle dysesthesia or changes in bowel and bladder habits.  Physical examination showed a non-antalgic gait.  There was tenderness over the T7-T8 and L5-S1 spinous processes, but the paraspinous muscles were nontender as were the sacroiliac joints, piriformis muscles, and the sciatic notch.  There were no spasms.  The CI was able to rise on her heels and toes without difficulty.  ROM measurements were flexion 100 degrees (normal 90) and combined ROM 240 degrees (normal).  Painful motion was not mentioned, but at an orthopedic visit on the same day, painful motion with the same ROMs was not present.  Deep tendon reflexes of the lower extremities were 2+/4; strength was normal; and sensation was intact.  Straight leg raising (to determine nerve root irritation) was normal and Faber’s test (to determine hip pathology) was negative.  At the VA C&P examination, the CI reported back pain, worse with prolonged standing or sitting.  Physical examination showed ROM measurements for flexion 0-90 degrees and combined ROM of 235 degrees, all with pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), citing painful motion in the face of preserved ROM.  The VA also  rated the back condition 10%, 5243 (intervertebral disc syndrome [IVDS]), based on the C&P examination, citing painful motion and reduced flexion to 80 degrees after repetition.  

The panel noted that the PEB assigned a 10% rating based on painful motion although there was insufficient limitation of motion; however, panel members could not confirm painful motion, but noted tenderness at the T7-T8 and L5-S1 spinous processes, which represents localized tenderness not resulting in abnormal gait or abnormal spinal contour, thereby warranting a 10% rating.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the degenerative arthritis L5-S1 and multi-level facet arthrosis condition.  

BOARD FINDINGS:  In the matter of the right inferior pubic ramus condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right degenerative arthritis L5-S1 and multi-level facet arthrosis condition and IAW VASRD §4.71a, the panel 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.  

AR20190004842, XXXXXXXXXXXXXXXXXXXX

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Dear XXXXXXXXXXXXXXXXXXXX:

	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.