RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201440 SEPARATION DATE: 20030616 BOARD DATE: 20130319 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (31U/Signal Systems Support Specialist), medically separated for bilateral hip pain. The hip pain condition began in 2000, improved, but then recurred in 2001. It was not a consequence of trauma or associated with a surgical indication. Bilateral hip pain could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was consequently issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The hip pain, characterized as “chronic hip pain bilaterally,” was forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated the bilateral hip pain as unfitting, rated 10%, referencing US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: “They have progressively become worse. Right shoulder tendonitis- seems as if the pain travels down arm to wrist and hand; making it hard to write and/or use computer which is the bulk of my job. Trochanteric Bursitis, left & right hip – very hard to get sleep at night; also hard to stand or sit for prolonged periods of time.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in Department of Defense Instruction (DoDI) 6040.44 (Enclosure 3, paragraph 5.e.2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The rating for the unfitting bilateral hip pain condition is addressed below. The requested right shoulder tendonitis was not identified by the PEB, and thus is not within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for the Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20030228 VA (4 Mo. Pre-Separation) – Effective 20030617 Condition Code Rating Condition Code Rating Exam Bilateral Hip Pain due to Stress Fracture and Reaction 5099-5003 10% Trochanteric Bursitis, Left Hip 5019-5252 10% 20030221 Trochanteric Bursitis, Right Hip 5019-5252 10% 20030221 .No Additional MEB/PEB Entries. Right Shoulder Tendonitis 5299-5203 10% 20030414 0% X 0 / Not Service Connected x 2 Combined: 10% Combined: 30% * *Includes 1.9% bilateral factor for 5252 codes ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment and worsening severity with which her service-incurred condition continues to burden her. It is a fact, however, that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. This role and authority is granted by Congress to the Department of Veterans’ Affairs. Bilateral Hip Pain. The PEB combined left and right hip pain as the single unfitting and solely rated condition, coded analogously to 5003. Although this approach complies with AR 635.40 (B.24 f.), the Board must apply separate codes and ratings in its recommendations, if compensable ratings for each condition are achieved IAW VASRD §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself. Not uncommonly this approach by the PEB reflects its judgment that the constellation of conditions was unfitting; and, that there was no need for separate fitness adjudications, not a judgment that each condition was independently unfitting. Thus the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB. The CI first developed hip pain during basic training, which was treated in February 2000. Although the narrative summary (NARSUM) reported that this pain was in the right hip, careful review of the entire record indicates that she was seen and treated for only left hip pain in basic training. Symptoms improved, but left hip pain again developed in August 2001. A bone scan on 30 August 2001 noted a faint stress reaction and a possible early stress fracture in the left inferior pubic ramus. The record was silent regarding any hip pain from November 2001 until September/October 2002, at which time she reported "two years of bilateral hip pain." This was the first reference to any right hip problem. A follow-up bone scan was performed on 23 October 2002, which showed possible persistent stress reaction but without definite evidence of stress fracture. A profile for bilateral hip pain was first written in October 2002. A primary care clinic evaluation on 2 December 2002 (6 months prior to separation) stated that the chronic bilateral hip pain was directly related to physical activity (especially running and jumping), but that she could do her job except when she went to the field and had to wear a Kevlar vest and a rucksack. Examination noted "full ROM" and tenderness of each greater trochanter. At the NARSUM exam, 5 months prior to separation, the CI complained of an inability to run or jump because of her pain. It was also difficult to sit or walk for prolonged periods, or to lift; but she could perform basic activities of daily living. Physical examination noted a normal gait and "full range of motion of the hips." Tenderness was present on deep palpation of the greater trochanteric areas bilaterally. Pain of each hip was elicited with full abduction. At the VA Compensation and Pension (C&P) exam 4 months prior to separation the CI noted that her bilateral hip pain was intermittent, could occur as often as every day and could last hours until she took Motrin. Pain caused her to walk slowly, but she could climb stairs and push a lawn mower. Examination revealed a normal posture and gait. Some tenderness at the greater trochanter was present bilaterally. ROM measurements reported 30 degrees of extension (normal to 20 degrees, although examiner stated normal was 30 degrees), adduction of 25 degrees (normal 45 degrees although examiner stated normal to 25 degrees), abduction 40 degrees (normal 45 degrees) and external rotation to 50 degrees (normal 45 degrees but examiner stated normal to 60 degrees). Painful motion was present on abduction, external rotation and internal rotation. Flexion was limited to 90 degrees (normal to 125 degrees), at which point pain was noted. X-rays of the hips were normal. The Board directs attention to its rating recommendation based on the above evidence. As previously elaborated, the Board must first consider whether right hip pain remains separately unfitting, having de-coupled it from a combined PEB adjudication. In analyzing the intrinsic impairment for appropriately coding and rating the right hip pain condition, the Board is left with a questionable basis for arguing that it was indeed independently unfitting. Despite the statements just prior to the MEB process that bilateral hip pain was present for 2 years, the above evidence indicates that only a left hip problem was documented from the time of basic training until the MEB process. After a temporary profile for the left hip expired in 2001, the record was then silent regarding any hip issues for approximately 10 months (i.e. shortly before the MEB process). After due deliberation, the Board agreed that evidence does not support a conclusion that right hip pain, as an isolated condition, would have rendered the CI incapable of continued service within her MOS; and, accordingly cannot recommend a separate rating for it. Next, the Board turned its attention to the left hip. The VA cited painful motion as the rationale for assigning a 10% rating under a combined 5019-5252 code (bursitis; thigh, limitation of flexion of). Board members agreed that in the absence of compensable limitation of motion, there was sufficient evidence of painful motion (VASRD §4.59) to warrant a 10% rating under either the PEB's or VA's coding pathways. The Board determined that there was no route to a rating higher than 10% under any applicable hip code. Given the findings regarding the right and left hip as just elaborated, the Board concluded that there was no benefit to the CI in unbundling the bilateral hip condition. Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral hip pain condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. As discussed above, PEB reliance on the USAPDA pain policy for rating bilateral hip pain was operant in this case and it was adjudicated independently of that policy by the Board. In the matter of the bilateral hip pain due to stress fracture and reaction condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Bilateral Hip Pain Due to Stress Fracture and Reaction 5099-5003 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294 dated 20120624, w/atchs. Exhibit B. Service Treatment Record. Exhibit C. Department of Veterans’ Affairs Treatment Record. XXXXXXXXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXX, AR20130005515 (PD201201440) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl XXXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)