RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX CASE: PD12001430 BRANCH OF SERVICE: ARMY BOARD DATE: 20130327 SEPARATION DATE: 20031215 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63W10/Wheel Vehicle Repairer), medically separated for a bilateral hip condition. She experienced an onset of right hip pain in 2002; was seen by multiple Primary Care and Orthopedic providers; and, underwent an array of treatment modalities. Over time she developed bilateral hip pain, diagnosed as trochanteric bursitis, which could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS). She was consequently issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The condition was forwarded, as a bilateral diagnosis, to the Informal Physical Evaluation Board (IPEB) IAW AR 40-501. No other conditions were submitted by the MEB. The IPEB adjudicated the condition as a single unfitting bilateral condition, rated 0%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI appealed to a Formal PEB (FPEB), which affirmed the IPEB findings; and, was thus medically separated with a 0% disability rating. CI CONTENTION: “This to letter is to explain why I feel that the rating I received for the conditions which rendered me unfit for duty should be changed. When I first enlisted in the military I did not have any problems with my feet or my hips. While serving in the military I suffered and continue to suffer from pain in my hips, legs, and feet. Since being discharged from active duty I have had to have surgery on my right foot and still need surgery on the left foot. I have also had other problems to develop due to the conditions that rendered me unfit. I now have a bulging disc in my lower back which causes major pain and sometimes causes me to have limited mobility. These reasons and others not listed should warrant a change in my rating.” [sic] SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting hip condition(s) is addressed below. The requested foot and lumbar conditions were not identified by the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board. Those, and any other conditions or contention not requested in this application, remain eligible for future consideration by the respective Board for Correction of Military Records. The Board acknowledges the CI’s information regarding the significant impairment with which her service- connected conditions continue to burden her but must emphasize 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. That role and authority is granted by Congress to the Department of Veteran Affairs, operating under a different set of laws. RATING COMPARISON: Service FPEB – Dated 20031001 VA - (4 Mos. Post-Separation) Condition Code Rating Condition Code Rating Exam Trochanteric Bursitis, Bilateral Hips 5019 0% Bilateral Trochanteric Bursitis 5019 0%* 20040415 No Additional MEB/PEB Entries Not Service-Connected x 1 20040415 Combined: 0% Combined: 0% Derived from VA Rating Decision (VARD) dated 20040706, most proximate to date of separation (DOS). * 5019 was increased to 10% left and 10% right in VARD dated 20071114 effective 20050228. ANALYSIS SUMMARY: Bilateral Hip Condition (Chronic Trochanteric Bursitis). The narrative summary (NARSUM) notes a chief complaint of chronic bilateral hip pain with the right being worse than the left. The CI was seen multiple times for her hips and was treated with physical therapy, non-steroidal anti- inflammatory medication, occasional narcotic pain medication for severe pain and two steroid injections without improvement. The examiner stated “the pain is made worse with normal daily activities required for her MOS and also with running, jumping, marching and sit-ups. The patient also states that carrying a ruck sac with increased weight seems to make the pain much worse.” X-rays were normal and bone scan demonstrated mild uptake in the right hip. The NARSUM, 5 months prior to separation, noted bilateral hip tenderness (right greater than left) with bilateral flexion to 90 degrees (normal 125 degrees), abduction 45 degrees (normal 45 degrees) and adduction of 10 degrees (normal 45 degrees). The examiner specified “negative pain with internal/external rotation” with negative pelvic rock. The DD Form 2808 two months prior to the NARSUM documented painful rotation bilateral hips. A treatment note 2 months after the NARSUM indicated “full active ROM (range-of-motion) with discomfort” and the physician started Elavil for neuromodulator effect (for pain) and refilled narcotic pain medication. The preponderance of treatment notes and the injections were for the right hip. The left hip pain was first noted in March 2003, 10 months prior to separation as part of bilateral hip pain. The left hip was next addressed in the record in July 2003, with diagnosis of left hip bursitis in August 2003 (4 months prior to separation). At the VA Compensation and Pension (C&P) exam 4 months after separation, the CI reported bilateral hip problems with bilateral popping with motions. She noted pain of 7 out of 10 was constant and similar in both hips; it increased to 8 out of 10 with walking greater than a-half to a mile, prolonged standing or sitting. ROM was specified as active 0-125 degrees (normal 125 degrees) with increased pain on repetition and left hip decreased flexion to 120°. Gait was normal and the CI was able to squat without difficulty. The VA examiner specified “no facial grimacing” on knee exams and “complains of pain she has no grimacing, no change in her facial expression” on feet exams, with no similar comments on the hip exams. Radiographs were normal. Fourteen months remote from separation (February 2005), the VA record indicated bilateral hips with pain-limited motion. The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the left and right hip conditions under a single disability rating, coded 5019. Although VASRD §4.71a permits combined ratings of two or more joints under 5019, it allows separate ratings for separately compensable joints. IAW DoDI 6040.44 the Board must follow suit if the PEB combined adjudication is not VASRD compliant, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for service rating. If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (Higher of two evaluations), separate ratings are recommended with the stipulation that the result may not be lower than the overall combined rating from the PEB. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings. The issues concerned whether each hip was separately unfitting if unbundled from a combined FPEB determination, and if each hip were separately compensable. The Board first considered if the right hip condition met the unfitting threshold for separate rating. The right hip was specifically profiled, had abnormal bone scan, was injected twice and was of the longest duration. Members agreed, therefore, that the right hip condition was reasonably justified as separately unfitting and that it met VASRD §4.71a criteria for separate rating, conceding painful motion for a 10% rating. The Board next considered if the left hip condition met the unfitting threshold for separate rating. The left hip was noted in the treatment notes, NARSUM, and PEBs as being much less symptomatic than the right hip. The left hip was not listed on the profile, but it would be speculative to separate restrictions from the right hip as not applying to the left hip. The NARSUM indicated bilateral hip worsening over the course of treatment, and it is common for the opposite paired leg to have increased stresses and symptoms with chronic disabilities. The Board considered that the record was very sparse on left hip pain or functional limitations until proximate to the MEB, the left hip was not noted on the profile, and did not have any imaging abnormalities. The Board consensus was that there was questionable basis for a separately unfitting left hip and that rating it, if separately unfit, would be 0%. The Board discussed VASRD §4.40 (Functional loss), §4.59 (Painful motion), ROM ratings under codes 5019, and code 5003 criteria, separately rating each hip, and combining both hips IAW VASRD 4.71a. The Board consensus was there was no benefit to the CI for separately rating each hip versus rating both hips analogously to VASRD code 5003 (or any of the diagnostic codes 5019 through 5024 which use the criteria from 5003). After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), §4.40 (Functional loss), and §4.59 (Painful motion), the Board majority recommends a disability rating of 10% for the Bilateral Hips condition coded 5099-5003. 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. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the bilateral hip condition, the Board by a 2:1 vote recommends that the bilateral hips condition, coded 5099-5003 be rated at 10% IAW VASRD §4.71a. The single voter for dissent (who recommended each hip be separately unfitting coded 5019 at 10% each), did not elect to submit a minority opinion. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation: UNFITTING CONDITION VASRD CODE RATING Trochanteric Bursitis, Bilateral Hips 5099-5003 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120608, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxx, AR20130008722 (PD201201430) 1. 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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)