RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE: PD-2017-04047 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20070506

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Corrections Specialist, medically separated for “bilateral hip pain” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  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 – 20070506	VARD - 20080630	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip Pain	5099-5024	0%	Trochanteric Bursitis, Right Hip	5252-5019	10%	20080408	
Right Hip Greater Trochanteric Bursitis	Not Unfitting	Hip Injury/Joint Pain/ Trochanteric Bursitis Left Hip	5252-5019	NSC	20040804	
Mechanical Low Back Pain	Not Unfitting	Lumbar Strain	5237	10%	20040804	
Multiple Stress Fractures	Not Unfitting	Residuals, Fractured Right Foot	5284	NSC	20040804	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Bilateral Hip Pain. The PEB combined the right and left hip conditions under a single disability rating, analogously coded 5099-5024 (tenosynovitis) and rated 0% 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’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.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral hip pain began in July 2004 after she sustained a right foot stress fracture during basic training. She subsequently developed a right femoral neck stress fracture which was treated with crutches, physical therapy (PT), and convalescent leave. A bone scan revealed a healed stress fracture, but she continued to have hip and back pain (not in the scope of review).

From 2005-2006, she received multiple steroid injections, which included the right sacroiliac (SI) joint and back, without any relief. At an examination on 12 September 2005, there was greater trochanter tenderness of the right hip, and positive Scour (to determine SI pathology) and Faber’s (to determine hip pathology) tests. Electrodiagnostic studies on 7 December 2005 were essentially normal, except for some prolongation of the motor distal latency across the ankle for the right posterior tibial nerve, which was reflective of an ankle fracture many years earlier.

Orthopedic examination on 23 January 2006 revealed right hip pain that was greater than the back pain. The provider also noted snapping of the hip and diagnosed of right hip greater trochanteric bursitis. The CI was given a combination steroid/anesthetic injection to the right trochanteric bursa. At a PT visit on 30 January 2006, she complained of right hip popping, and the examiner diagnosed SI/pubic ramus dysfunction.

During the 18 July 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 12 months prior to separation, the CI reported a right hip femoral hip stress fracture. Physical examination revealed right hip pain on external and internal rotation. At an orthopedic follow-up on 14 August 2006, she had decreased sensation of the anterior lateral right thigh without tenderness, but the examiner documented “doubt meralgia paresthetica [tingling, numbness and burning on the lateral thigh due to compression of the lateral femoral cutaneous nerve].”

The 5 December 2006 MEB orthopedic examination, 5 months before separation, showed tenderness of the right hip trochanteric bursa and the hip, with snapping present, but no instability noted. The MEB NARSUM examination the next day, noted complaints of bilateral hip pain. Physical examination revealed normal heel and toe walking and sensation, and full bilateral hip range of motion (ROM) with pain at extremes of motion on the right hip and a snapping sensation on both hips. The examiner diagnose “right hip greater trochanteric bursitis with chronic pain, history of multiple stress fractures, and snapping hip syndrome.”

At the 8 April 2008 VA Compensation and Pension (C&P) examination, 11 months after separation, the CI reported bilateral hip pain. No assistive devices were required and treatment consisted of a nonsteroidal anti-inflammatory drug. Physical examination showed posture and gait within normal limits. There was bilateral hip tenderness, but no edema, effusion, weakness, redness, heat, guarding of movement and subluxation. Measured hip ROM showed bilateral flexion to 120 degrees (normal 125) with endpoint pain. The remainder of the hip motions were normal on each side, and joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Bilateral hip X-rays were negative.

The panel directed attention to its rating recommendation based on the above evidence. As noted above, the PEB rated the bundled the right hip and left hip conditions 0%, coded 5099- 5024, citing no significant bilateral loss of hip motion or joint instability. The VA rated the right hip condition 10%, coded 5252-5019 (bursitis), based on the C&P examination, citing “painful or

limited motion of a major joint or group of minor joints, and may also be applied once to multiple joints if there was no limited or painful motion.” The VA did not service-connect the left hip, based on the C&P examination, citing the evidence did not show the condition either occurred in or was caused by service. Panel members noted that although VARSD §4.71a permits combined ratings of two or more joints under 5003 (arthritis, degenerative), it allows separate ratings for separately compensable joints. If supported under VASRD §4.71a, separate ratings for PEB bilateral joint adjudications may be recommended by the panel if it determines that each joint is reasonably justified as separately unfitting.

The panel first considered the right hip condition, and agreed that evidence of functional limitations of the right hip could be reasonably justified as separately unfitting since the it was profiled, implicated by the NARSUM, and the profile was referred to in the commander’s statement. Panel members noted there was no evidence of hip ankylosis (5250), thigh limitation of extension or flexion (5251 or 5252), thigh impairment (5253), or hip flail joint (5254). However, there was right femur impairment with residual pain as a result of the antecedent stress fracture. Therefore, the panel determined use of analogous code 5299-5255 (malunion with slight hip disability) was reasonable. Additionally, there was full right hip ROM, but pain at the extreme ends of the motions at the MEB NARSUM examination, and at 120 degrees at the VA examination, thereby suggesting consideration of a 10% rating under code 5099-5003 for painful motion. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right hip pain condition, coded 5299-5255.

The panel then considered whether the left hip pain was reasonably justified as separately unfitting, and noted that it was not profiled or implicated in the commander’s statement. Additionally, the STR did not document that the functional limitations of the left hip interfered with duty performance, especially since many of the examinations prior to separation indicated complaints were focused on the right hip pain only. The NARSUM examiner did not list left hip pain as a final diagnosis, although there was pain noted on the extremes of hip motion bilaterally. The VA examiner noted a normal gait with bilateral hip tenderness and painful motion beginning at flexion of 120 degrees bilaterally, although there was no explanation why the ROMs were less than full. Therefore, the panel determined the left hip pain did not significantly interfere with the CI’s performance of duties at the time of separation. After due deliberation in consideration of the totality of the evidence, members agreed that the left hip condition was not reasonably justified as separately unfitting, and so no additional disability rating is recommended.

Contended PEB Conditions: Right Hip Greater Trochanteric Bursitis, Mechanical Low Back Pain (LBP), and Multiple Stress Fractures. The panel’s main charge is to assess the fairness of the PEB’s determination that contended conditions were not unfitting. The panel noted that the right hip greater trochanteric bursitis was related to the right hip pain and determined the diagnosis was not a separate condition which could be reasonably justified as separately unfitting; nor would a separate rating be achievable without violation of VASRD §4.14 (avoidance of pyramiding). There was no performance-based evidence from the record that any of the contended conditions significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended conditions, so no additional disability rating are recommended.

BOARD FINDINGS: In the matter of the right hip condition, the panel recommends a disability rating of 10%, coded 5299-5255 IAW VASRD §4.59. In the matter of the left hip condition, the panel determined it to be not separately unfitting. In the matter of the contended right hip greater trochanteric bursitis, mechanical low back pain, and multiple stress fractures the panel recommends no change from the PEB determinations as not unfitting. 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	
Right Hip Pain	5299-5255	10%	

PD-2017-04047 

AR20190012023, XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXX

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.

PD-2017-04047