RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02702
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050602

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Unit Supply Specialist, medically separated for “left thigh and hip as well as knee pain” with a disability rating of 10%.  

CI CONTENTION:  The CI’s condition continues to worsen and negatively affects daily activities.  The complete submission is 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 - 20050425	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Thigh, Hip and Knee Pain	5099-5003	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Left Thigh, Hip and Knee Pain.  The PEB combined the left thigh, hip and knee conditions under a single disability rating, analogously coded 5099-5003 and rated 10% with application of the U.S. Army Physical Disability Agency pain policy.  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 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, thigh and knee conditions are 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 condition began in May 2004 during a road march.  X-rays revealed bilateral femoral neck stress fractures.  Physical therapy (PT) noted in August 2004 active range of motion (ROM) of both hips was within normal limits with pain on hip flexion and internal rotation.  Muscle strength of both hips was grossly at 4/5.  Faber and Scour testing (to determine hip pathology) was positive, but gait was normal.  However, orthopedics in November 2004 noted the CI ambulated with mild antalgia of the left lower extremity.  There was point tenderness of the left lower extremity but no deformity.  The MRI showed no evidence of a femoral neck fracture, but there was a left femoral shaft stress fracture without displacement with minimal cortical changes.  There was no obvious labral pathology and no avascular necrosis.  

During the 3 February 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported left thigh numbing.  Physical examination revealed left leg pain and a healed fracture of the left femur.  The commander’s statement indicated the CI had femur stress fractures and was unable to perform the duties of her MOS.  At an orthopedic clinic visit on 16 March 2005, the CI complained of left knee joint pain with posterior swelling and bruising.  On examination there was a mild effusion and the knees showed full ROM without exceptions.  There was a genu recurvatum of the left knee and pain was elicited by motion.  There was no genu varum or valgum, medial or lateral instability, laxity, or evidence of a meniscal tear.  An MRI of the left knee was normal.  The examiner noted that a prior MRI was negative for femoral neck stress fracture despite periosteal reaction noted on plain films to the inner aspects of both femoral necks.  The 31 March 2005 PT active range of motion (ROM) study showed left thigh flexion of 65 degrees (normal 125), extension of 5 degrees (normal 20), abduction of 15 degrees (normal 45) and adduction of 20 degrees (normal 25), all with pain, but on the right there was thigh flexion of 90 degrees with pain, 10 degrees of extension, 30 degrees of abduction with pain, and 20 degrees of adduction.  Left knee ROM was 0-105 degrees (normal 0-140) with pain and right knee ROM was -1-115 degrees with pain on flexion.  

The 11 April 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of left hip and thigh pain.  Physical examination showed a well-developed, well-nourished female in no acute distress.  She had mild antalgia of the left lower extremity and she walked with the use of crutches, although she was in regulation battle dress uniform with combat boots.  She had some tenderness about the knee and the mid shaft of the femur, but was neurologically intact.  X-rays showed no evidence of a femoral neck fracture but there was evidence of a healing femoral shaft fracture with minimal cortical change.  There was no evidence of periarticular knee fractures.  The examiner’s diagnosis was left femoral shaft stress fracture that was slow to resolve.  He noted that given the chronic nature of the CI’s symptoms with minimal resolution despite being on crutches, convalescent leave and 6 months of activity modification, it was unlikely that her symptoms would resolve in the current environment.  Furthermore, she was susceptible to stress reactions and likely would sustain others in a high impact environment.  

At the 11 April 2005 MEB NARSUM knee addendum the CI complained of left knee pain.  An MRI demonstrated a pristine joint space with no evidence of intra-articular loose bodies.  There was no evidence of avascular necrosis, bone marrow edema or meniscal or ligamentous pathology.  The examiner’s assessment was left knee pain with no acute surgical indications or internal derangement.  The examiner opined that it was most likely reactive and compensatory for the left hip pain.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left thigh, hip and knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing decreased hip and knee ROM due to pain.  Initially there was a report of stress changes (periosteal reactions) of the femoral neck bilaterally; however, a follow-up MRI of the left thigh confirmed a left femoral stress fracture.  Therefore, the panel determined that the left thigh was the primary unfitting condition, and as a result of that pathology, the left hip and left knee were secondarily unfitting since the femur is the physical link between the hip and knee.  The panel agreed that code 5255 (femur impairment with moderate knee or hip disability) was the most appropriate code and a 20% rating for the left lower extremity condition was supported because the femur stress fracture was slow to heal as evidenced by the fact that the CI was still on crutches during the NARSUM examination; the ROM of the left thigh was 50% of normal; X-rays initially showed femoral stress reactions and the knee was painful secondary to compensation for the left hip.  A higher rating of 30% requires marked knee or hip disability, which by the time of separation was not in evidence nor was the CI offered surgery or had surgery.  Alternatively, the panel considered a 60% rating using code 5255, which requires a “fracture of the shaft or anatomical neck of:  with nonunion, without loose motion, weight bearing preserved with aid of brace.”  However, a true break was not present, although a stress fracture was present that was reported to be healing.  Furthermore, the CI did not use a brace, although she presented to the NARSUM examination using crutches for use with the slow healing stress fracture.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left lower extremity condition, coded 5255.  

BOARD FINDINGS:  In the matter of the left lower extremity condition, the panel recommends a disability rating of 20%, coded 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	
Left Thigh and Hip as well as Knee Pain	5255	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170323, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190009140, 

Dear XXXXXXXXXXXXXXXXX:

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.