RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04144
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051028

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Unmanned Aerial Vehicle Operator, medically separated for “avascular necrosis of the left hip” with a disability rating of 20%.  

CI CONTENTION:  “I would like for my rating to be updated to reflect the VASRD that took effect in 2005.”  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 - 20050929	VARD - 20051206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Avascular Necrosis of the Left Hip	5099-5003	20%	Degenerative Joint Disease, Left Hip	5010-5255	30%	20051005	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Avascular Necrosis of the Left Hip.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left hip condition was first treated on 30 March 2005, 5 days after accession.  He reported a gradual onset of pain which was aggravated by standing and activity.  On 6 April 2005, the CI reported left hip pain when standing and that he had a leg length discrepancy.  An X-ray showed a one centimeter difference between the legs.  On 18 April, he reported that he had fallen about 15 feet from a tower a week earlier and had restricted movement of the left hip.  On examination, the range of motion (ROM) of the hips was normal and pain free.  Tenderness was absent.  One week later he reported twisting his left hip while climbing down from his bunk.  On examination, the ROM was reduced and painful.  In physical therapy the same day, it was noted that an X-ray showed possible Legg-Calve-Perthe Disease of the left hip (a childhood condition with avascular necrosis of the femoral head).  The findings included sclerosis and flattening of the hip (non-acute changes).  On examination, motion was painful but full and the gait was normal.  The CI was referred to orthopedics and seen on 12 May 2005.  The diagnosis of avascular necrosis (AVN) was confirmed.  The CI was then seen in primary care on 19 May 2005 and reported continued pain, but denied hip pain prior to accession or the use of steroids (or other risk factors for AVN).  He was limping on examination.  X-rays of the hip in August 2005 showed no significant change from the original X-ray.  

The 25 August 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of ongoing left hip pain despite the use of crutches (for partial weight bearing).  He denied risk factors for AVN.  On examination, flexion was limited to 80 degrees (normal 125) and external rotation to 20 degrees (normal 45).  Extension, abduction, and adduction were not recorded.  The NARSUM was updated 2 weeks later to note that the CI was likely to require surgery at some point in the future.  

At the 5 October 2005 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported that his pain was due to an injury on active duty.  [The panel noted that the pain was actually first recorded less than 1 week after accession and prior to any recorded injury.]  The CI also reported a total of 12 days of incapacitation; these were not found in the STR.  The physical examination showed a limp.  He used crutches to take pressure off his left hip and back.  The ROM showed flexion of 80 degrees, extension of 16 degrees (normal 20), adduction of 16 degrees (normal 25), abduction of 40 degrees (normal 45), external rotation of 44 degrees and internal rotation of 36 degrees (normal 40).  An X-ray showed the previously described femoral head flattening and sclerosis.  

The CI was seen in primary care on 30 December 2005, 2 months after separation.  He reported difficulty with driving, rising from a seated position and squatting (limited to a partial squat) although he could do these as well as climbing stairs.  The CI requested a handicap sticker at this visit which implied that he did not have one previously including the time of separation.  He had an abnormal gait and used a cane.  His motion showed flexion of 60 degrees, extension of 20 degrees, internal rotation of 15 degrees, external rotation of 0 degrees, adduction of 10 degrees and abduction of 15 degrees.  Strength was reduced, but atrophy was absent.  

At the 31 January orthopedics examination, 3 months after separation, flexion and extension were pain free and no limitations were documented.  Internal and external rotation were, respectively, 20 and 30 degrees and limited by pain.  X-rays showed AVN.  The gait was not recorded.  The CI was thought to be a candidate for a total hip replacement.  The CI was seen by another orthopedist on 30 March 2006, 5 months after separation.  He noted that he had quit smoking in December 2005 (he had previously denied tobacco abuse).  The ROM, in degrees, showed flexion of 70, extension of 0, internal rotation of 5, external rotation of 25, and abduction of 15.  A partial hip replacement was recommended.  This was accomplished on 5 December 2006, 13 months after separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left hip condition 20%, analogously coded 5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA also rated the left hip condition 20%, dual coded 5010-5255 (traumatic arthritis-femur impairment), based on the C&P examination, citing a moderate impairment.  A de novo review by a decision review officer increased the rating to 30%, retroactive to separation, on 27 October 2006 based in part on the post-separation evidence cited above.  It was determined that findings on an X-ray done on 31 January 2006 supported a finding of malunion with marked disability.  
The CI initially was evaluated for left hip pain 5 days after accession and did not report a history of trauma.  Changes consistent with AVN were present on the initial X-rays taken on 25 April 2005 and subsequent X-rays did not show a significant change.  At the time of the initial X-ray, the gait was normal and the ROM full.  The VA C&P examination was 3 weeks prior to separation.  It noted a limp and reduced ROM.  However, the ROM was not compensable under any of the codes specific for the hip (5251, 5252 or 5253).  The panel considered code 5255 and noted that there was collapse of the joint which appeared to be chronic in nature.  The increase in the subjective symptoms is not explained by the radiological findings which appeared to be relatively stable.  Although the CI requested a handicapped permit after separation, there is no evidence that one was issued or requested prior to separation.  The preponderance of evidence is more consisted with a moderate rather than a marked disability at separation, providing no rating advantage to the CI.  After due deliberation, considering all of 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 left hip condition.  

BOARD FINDINGS:  In the matter of the left hip 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.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170404, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006259, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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.

Sincerely,					      
Enclosure