[AR Number], XXXXXXXXXX. 

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

	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

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX.	CASE:  PD-2017-04863
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090404

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Human Resources Specialist, medically separated for “right pubic ramus stress fracture” with a disability rating of 20%.  

CI CONTENTION:  She should receive a higher rating.  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 - 20090129	VARD - 20090601	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Pubic Ramus Stress Fracture	5299-5255	20%	Stress Fracture, Right Inferior Pubic Ramus	5299-5255	20%	20100913	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Right Pubic Ramus Stress Fracture.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered a stress fracture of her right pubic ramus (pelvic structure supporting the hip socket) in January 2008 during basic training.  She had persistent pain and was treated with intermittent use of crutches and physical therapy (PT).  Although she completed basic and advanced training, she was never able to resume full physical activities required for military duty.  Follow-up imaging (serial X-rays and MRI) demonstrated a healing fracture, and surgery was not indicated.

Clinical entries in the STR showed periods of time when the CI was ambulating with a normal gait without crutches and pain-free with usual activities, interspersed with periods of gait disturbance and use of crutches.  Likewise, there were some entries that documented grossly normal hip range of motion (ROM) and others that indicated painful motion with non-specifically limited ROM.  The only quantified ROM measurements were performed for the MEB.  There was STR documentation of normal strength and the absence of instability or malalignment, and no entries that implicated severe ROM limitation or functional impairment, periods of incapacitation, or other ratable evidence.  

The 10 December 2009 MEB NARSUM examination, 4 months prior to separation, documented the CI’s complaint of persistent “right groin” pain (unquantified) and continued use of crutches “almost all the time.”  The profile prohibited running and all general soldiering requirements, but permitted bicycling.  The examiner stated, “She is able to shop and get around fairly freely… [although]…avoids heavy activities at this time, but I would expect continued improvement over time.”  The physical examination recorded periodic use of crutches with the ability to get on the examination table without difficulty.  There was tenderness over the stress fracture, normal strength (5/5), and guarding to hip flexion, extension, abduction and adduction.  Hip rotation and all passive ROM was normal.

Formal ROM measurements for the MEB were conducted by PT on 7 January 2009, 3 months before separation, and recorded flexion to 90 degrees (normal 125), extension to 5 degrees (normal 20), and abduction to 5 degrees (normal 45).  Adduction was intact to leg crossing and external rotation was intact to toe-out greater than 15 degrees.  The examiner documented the onset of pain as equivalent to measured ROM for extension and abduction.

At the 13 February 2009 VA Compensation and Pension (C&P) general examination, 2 months before separation, the CI reported constant pain “over anterior right pubis” rated at 7-8/10, but denied any hip pain.  The examiner documented that “she continues to use crutches for partial weight bearing” without specifying functional limitations.  The physical examination recorded a “mildly antalgic gait” with use of crutches, tenderness over the pubic ramus, and the absence of malalignment, instability, malunion, or other VASRD-ratable findings.  The examiner documented painful motion of the hip without providing ROM measurements.

Of note, a VA general physical examination on 26 June 2009, 3 months after separation, documented a normal gait without mentioning the use of crutches or assistive device.  A specific C&P joint examination on 13 September 2010, 16 months after separation, was the only comprehensive evidence probative to the overall clinical course.  That examiner documented that the CI was a full-time student, but still suffered significant limitations with prolonged standing (reported 30-minute tolerance) and walking (reported 1 block tolerance).  The physical examination recorded a “smooth gait with no associated limp” and no use of assistive device.  Measured ROM of the right hip was flexion to 120 degrees, extension to 5 degrees, abduction to 30 degrees, external rotation to 30 degrees, and adduction to 15 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right pubic ramus stress fracture 20%, coded 5299-5255 (analogous to impairment of the femur), citing the VASRD §4.71a “moderate” criterion for contiguous hip disability.  The VA also rated the right pubic ramus stress fracture 20%, coded 5299-5255, based on the C&P examination, citing the same “moderate” criterion.  Other than consideration of a 30% rating under code 5299-5255 for severe hip disability, there was no ROM limitation, ankylosis, flail joint or other ratable criterion that would justify a rating higher than the PEB’s 20% under any applicable code available in VASRD §4.71a.  It was noted that the MEB PT measurement of 5 degrees abduction satisfied a 20% criterion of code 5253 (thigh, impairment of); although, the probative value of this data was mitigated by the possibility that it reflected the onset of painful motion rather than full ratable excursion.  

Given the functional disability still present at separation, members agreed that analogous rating under criteria of code 5255, as employed by the PEB and VA, was the fairest and most favorable option IAW VASRD §4.7 (higher of two evaluations).  With regards to concession of a higher rating under 5299-5255, members agreed that the evidence was more reasonably aligned with moderate (20%) rather than severe (30%) disability.   It was acknowledged that the CI was still fairly dependent on crutches at the time of the NARSUM, but this was improving even by the time of the pre-separation C&P a month later (at which time the VA rater assessed moderate disability).  The normal unassisted gait within a few months of separation and the favorable clinical course documented in the VA post-separation evidence further supported a conclusion that the overall disability could not be reasonably characterized as severe.  This was also correlated with the anticipated clinical acuity associated with a diagnosis of stress fracture.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the right pubic ramus stress fracture.

BOARD FINDINGS:  In the matter of the right pubic ramus stress fracture 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.