RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE: PD-2017-04125 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20060104

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Military Police, medically separated for “bilateral hip pain” and “right index finger pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

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 - 20050920	VARD - 20060607	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Bilateral Hip Pain	
5019	
10%	Left Hip, Post Traumatic Osteoarthritis	5003-5252	10%	
20060323	
			Right Hip, Post Traumatic Osteoarthritis	5252	10%		
Right Index Finger	5099-5003	0%	Right Palm Status Post Ganglion Cyst	5215-7804	10%	20060323	
Headaches	MEB Diagnosis	Pituitary Microadenoma	8100-8003	10%	20060222	
Hypohysial Microadenoma	MEB Diagnosis					
Weight Gain	MEB Diagnosis	No VA Placement	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Bilateral Hip Pain. The PEB combined the right and left hip conditions under a single disability rating, coded 5019 (bursitis) and rated 10%. 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 experienced bilateral hip pain while in basic training without injury or trauma. On 16 June 2004, MRI studies revealed fluid at the insertion of the gluteus tendon of the greater trochanter in both hips, probably representing bursitis. During the 6 April 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported bilateral hip pain and bursitis, and the examiner noted she was “unable to do squat secondary to hip and knee pain,” with a summary of “chronic hip pain– significant loss of ability to perform military duties.”

The 29 April 2005 MEB NARSUM examination, 8 months before separation, noted complaints of chronic bilateral hip pain. Physical examination revealed tenderness over both greater trochanters. Physical therapy (PT) range of motion (ROM) measurements from 28 April 2005 were listed and each hip had extension greater than 5 degrees, flexion greater than 45 degrees, abduction greater than 10 degrees and rotation over 15 degrees. The CI was “able to squat down with some difficulties. Gait was adequate, although with short steps.” The diagnosis was chronic bilateral hip bursitis. Orthopedic examination on 29 April 2005 revealed pain in both hips at the end of ROM. On 8 August 2005, PT evaluation revealed full bilateral lower extremity ROM with pain at the end range of internal rotation. Orthopedic examination on 18 August 2005 revealed a mild positive O’Brien’s labral test (equivalent to painful motion) of both hips.

At the 23 March 2006 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported daily bilateral hip pain and stiffness. A C&P examination from the prior day revealed a normal gait. The examiner found painful motion of both hips with ROM showing each hip had extension greater than 5 degrees, flexion greater than 45 degrees, abduction greater than 10 degrees and rotation over 15 degrees. Following repetition there was additional limitation of 15 degrees due to pain and lack of endurance. An MRI showed bilateral trochanteric bursitis and left hip osteoarthritis.

The panel directed attention to its rating recommendation based on the above evidence. As noted above, the PEB bundled the right and left hip conditions and applied a single 10% rating (coded 5019). The VA rated each hip condition 10%, with the left hip dual coded 5003-5252 (degenerative arthritis-thigh, limitation of flexion) and the right hip coded 5252, based on the C&P examination, noting painful motion and citing osteoarthritis and limitation of motion. As previously elaborated, the panel must first consider whether each hip condition remains separately unfitting, having been de-coupled from a combined PEB adjudication. The panel noted that bilateral hips were permanently profiled L3, implicated in the commander’s statement and the NARSUM, and failed retention standards. 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 knee over the other. Since undue speculation would be required to conclude that impairment from either hip would not have unacceptably

interfered with continued military specialty performance, members agreed that each hip was reasonably justified as separately unfitting.

The panel then considered the rating recommendation for each hip condition at the time of separation, noting that the objective findings and associated disability for each hip were identical (aside from left hip arthritic changes), and that the respective ratings should therefore be the same. There was no compensable limitation of hip motion under codes 5250 thru 5253 for either the right or left side. However, the MEB PT formal ROMs documented active ROM less than passive ROM, the NARSUM indicated difficulty with squatting, and the orthopedic evaluation and VA examination documented painful motion. The panel adjudged that there was sufficient evidence of painful motion causing functional loss (based on §4.59, §4.40 and §4.45) to support a 10% rating for each hip. Coding under 5019 was reasonable, and alternative rating analogous to code 5255 (femur impairment), or other codes would rate no higher than 10% for either hip. After due deliberation, and considering all the evidence, the panel recommends a disability rating of 10% for the right hip condition and 10% for the left hip condition, each coded 5252-5019.

Right Index Finger. According to the STR and the MEB NARSUM, the right-handed CI had a painful mass at the base of the right index finger metacarpophalangeal joint that was firmly attached to the volar base of the proximal phalanx (where the index finger joins the hand). She underwent ganglion cyst excision of the flexor tendon (with partial tendon sheath excision) in April 2004. During a 19 August 2004 consult, the provider indicated the pathology report showed a giant cell tumor excision with involved margins, and that the tumor was beginning to grow again, with pressure on the tumor causing pain.  The CI was referred to a civilian hand specialist.

An orthopedic evaluation from 3 February 2005 indicated minimal improvement with treatment from the civilian hand specialist, and that the CI could not fire a weapon “secondary to hand.” Examination showed a tender, well-healed scar and full ROM and strength, but decreased sensation to the ulnar side of the index finger and radial side of the middle finger. The impression was “persistent hand pain and digital n. [nerve] dysfunction [after] hand surgery.” The MEB NARSUM examination noted CI complaints of exertional pain, paresthesias, and the inability to fire a weapon due to the finger. Physical examination showed a tender scar over the volar aspect of the right index finger. There was “adequate” ROM, with normal strength and distal sensation, and he could make a fist.

The CI’s 20 June 2005 MEB (PEB evaluation) rebuttal indicated that she had difficulty using the right hand: “Overtime, I realized that the feeling in my hand was not the same. If I tried to fire a weapon, I would get this sharp pain shooting up and down my arm. Or if there was any pressure put on the (post-surgical) area it would be very painful.” Pain was exacerbated by typing or writing, and at times the she got cramps during activities using the hand.

At the 22 March 2006 C&P examination, 3 months after separation, the CI reported right hand pain and stiffness. Physical examination showed right palm (thenar area) tenderness but normal bilateral hand/finger strength and ROM (no gap between thumb-ring finger, fingertips to transverse crease, and thumb pad to opposing fingers). The examiner indicated that intermittent pain and lack of endurance additionally affected hand function; X-rays were normal.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right index finger condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy. The VA rated the right hand condition 10%, dual coded 5215-7804 (wrist, limitation of motion-scars, superficial, painful on examination), based on the C&P examination, citing painful palm from cyst excision. Panel members considered that the CI’s surgery was at the junction of the index finger and the hand involving the index finger flexor tendon sheath, and that the index finger and palm pain were essentially the same condition. There was no ankylosis or limitation of motion of the index finger

for rating under codes 5225 or 5229. The right index finger pain was noted to be associated with pain on use and pressure, paresthesias, and shooting (radiating) pain symptoms, and the panel deliberated over whether the CI’s post-surgical pain and disability was analogous to a painful scar or neuralgia (nerve irritation). Although, both the NARSUM and C&P examinations documented a painful scar with functional loss following cyst excision, potentially supporting a 10% rating coded 7804 (scars, superficial, painful on examination), the panel considered that the totality of the CI’s disability picture, and with keeping to the PEB’s diagnosis of “right index finger pain post removal of a ganglion cyst,” that interfered with duty performance, that analogous coding to 8715 (neuralgia, median nerve) was predominant. The panel majority adjudged code 8715 at the mild (10%) level best represented the CI’s disability picture at separation. There was no paralysis or sufficient symptoms to meet the next higher moderate (30%) rating criteria. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the right index finger condition, coded 8799-8715.

Contended PEB Conditions: Headaches, Hypohysial Microadenoma and Weight Gain. None of the conditions were profiled or implicated in the commander’s statement, and did not fail retention standards. The weight gain is a condition not constituting a physical disability IAW DoDI 1332.38. Therefore, the panel has no basis for recommending it as unfitting. There was no performance-based evidence from the record that any of the other conditions significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend any of the contended conditions be found unfitting or ratable, so no additional disability ratings are recommended.

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 5252-5019 and rated 10% and an unfitting left hip condition coded 5252-5019 and rated 10%, both IAW VASRD
§4.71a. In the matter of the right index finger condition, the panel majority recommends a disability rating of 10%, coded 8799-8715 IAW VASRD §4.124a. The single voter for dissent recommends modification to 20% and did not elect to submit a minority opinion. In the matter of the contended headaches, hypohysial microadenoma and weight gain, the panel agrees it cannot recommend any for additional disability rating. 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Right Hip Pain with Clinical Assessment of Hip Bursitis	5252-5019	10%	
Left Hip Pain with Clinical Assessment of Hip Bursitis	5252-5019	10%	
Right Index Finger Pain Post Removal of Ganglion Cyst	8799-8715	10%	
	COMBINED	30%	

The following documentary evidence was considered:

PD-2017-04125 

AR20190010941, XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a permanent disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a permanent disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

PD-2017-04125