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AF | PDBR | CY2011 | PD2011 01093
Original file (PD2011 01093.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE NUMBER: PD1 1 0 1093
BRANCH OF SERVICE: Army   BOARD DATE: 2013 0507
Separation Date: 20011125


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (63B / Light Wheeled Mechanic) medically separated for chronic bilateral hip pain. The CI claimed her original injury was the result of an accident in 1987; however, she was cleared to enter military service in 1989. She reinjured her left hip in a parachute jump in 1993. The 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 issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded “ chronic bilateral hip pain, existed prior to service ( EPTS ) history of (b) hip fracture, service aggravated; chronic pelvic pain; endometriosis, status post ( s/p ) total abdominal hysterectomy; a nd latex allergy ” to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. No other conditions were submitted by the MEB. An administratively corrected PEB adjudicated “ chronic bilateral hip pain with a history of acetabular fractures” as unfitting, rated 10% with likely application of the US Army Physical Disability Agency (U SAPDA) pain policy, the Veteran s Affairs Schedule for Rating Disabilities (VASRD), and compensability under 10 USC § 1207a . The PEB adjudicated the chronic pelvic pain, endometriosis, and the latex allergy as not unfitting. The CI made no appeals, and was medically separated with a 10% disability rating.


CI CONTENTION : “Chronic bilateral hip pain with history of bilateral acetabular fractures. I believe it was inaccurate because the examination was no t thorough enough. After separation it was discovered that the injury I incurred with my hip & pelvic fracture even caused lower back pain and nerve damages.” [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 bilateral hip condition is addressed below and no additional conditions are 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 Correction of Military Records.


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Service Admin IPEB – Dated 20011004
 VA - (4 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilateral Hip Pain 5099-5003 10% Pelvic Hip Fracture 5299-5252 Not Service Connected
(NSC*)		 20020320
Chronic Pelvic Pain Not Unfitting
Endometriosis, S/P Total Abdominal Hysterectomy Not Unfitting S/P Hysterectomy and Bilateral Oophorectomy 7617 50% 20020320
Latex Allergy Not Unfitting Latex Allergy 7899-7825 NSC
No Additional MEB/PEB Entries
 Other x 2 20020320
Combined: 10%
 Combined: 50%*
VARD of 20030724 added Degenerative changes of the L-Spine, 5299-5295, 10%, effective 11/26/01, day after separation, increasing combined to 60%. DRO Decision of 20040824, using an August 2003 exam at Ft. Eustis, awarded traumatic degenerative joint disease, left hip, 5010-5252, 10%,; and using an original March 02 C&P exam, awarded pelvic adhesive disease, 7614, 10%, both effective 11/26/01, increasing combined to 80%. VARD of 20120710 awarded right hip strain, degenerative change of the right hip, 5252, 10%, effective 11/26/01, keeping combined at 90%, which was increased by DRO Decision of 20071221.

ANALYSIS SUMMARY : The Board acknowledges the CI’s assertions that the examination was not thorough enough. It is noted for the record that the Board has neither the jurisdiction nor authority to scrutinize or render opinions in reference to the CI’s statements in the application regarding suspected improprieties in the processing of his case. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. It must also judge the fairness of PEB fitness adjudications based on the fitness consequences of conditions as they exi sted at the time of separation.

The PEB rated chronic bilateral hip pain under the single analogous code 5099-5003 arthritis, degenerative (hypertrophic or osteoarthritis) code. This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation. The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each joint 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 reasonably justified as unfitting in and of itself.
Bilateral Hip Pain Condition . The Board first considered if the right and left hip pain, having been de-coupled from the combined PEB adjudication, each remained independently unfitting as established above. The CI was on a permanent L3 profile with significant limitations that would have resulted from either condition alone. The commander’s statement documented that the restrictions of no marching, jumping, squatting, climbing, heavy lifting , bending , or stooping limited the CI performing her MOS. A majority of the Board members agreed that the right and left hip pain, as isolated conditions, would have each rendered the CI incapable of continued service within her training for her MOS and accordingly merit separate ratings.
There were two goniometric range - of - motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Hip ROM in Degrees
 MEB ~10 Mo. Pre-Sep VA C&P ~ 4 Mo. P ost -Sep
Left Right Left Right
Flexion (0-125)
 125 ( 130 ) 125*
Extension (0-20)
 - 20 ( 30 )
Exertional Rotation (0-45)
 45 ( 70 ) 45 ( 60 )
Internal Rotation(0-45)
 30 40
Abduction (0-45)
 - 45
Adduction (0-45)
 - 25* 20*
Normal gait; ability to forward flex to mid shin, laterally bend to mid-thigh, hyperextend approximately 10°; some tenderness over sacroiliac joint (SIJ);no paravertebral muscle tenderness; no inguinal tenderness; strength 5/5; sensory intact; no local tenderness; negative straight leg raise bilaterally; test can only elevate both lower extremities to 30° due to tight hamstrings; reflexes 2+ *with pain;
§4.71a Rating
 10% 10% 1 0% 1 0%
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The CI claimed that she injured both hips in May 1987 and sustained a pelvic fracture and left knee fracture . The a pplicant p re- s creen f orm did not indicate any previous hip fractures or injuries and the CI was cleared for acceptance into the Service. The CI claimed that she injured her pelvis in a jump in 1993 she was hospitalized for 3 days, placed on crutches for 3 months and eventually recovered. The CI was seen for bilateral hip pain in late 1995 and was given a permanent L2 Profile for chronic left hip pain, s / p bilateral acetabular diagnosis (DX) EPTS . The o rthopedist noted chronic left hip pain and a history of bilateral acetabular fractures. X-rays of both hips done revealed a left acetabulum bone sclerosis and double cortical density in the inner aspect of the acetabulum; however , the right acetabulum was normal. The CI was evaluated in June 2000 for left inguinal pain and there were physical findings of some tenderness over the left sacroiliac joint ( SIJ ) , bilateral hip flexion to 130 degrees, internal rotation to 30 degree; straight leg indicated tight hamstrings with elevation only to 30 degrees; however full external rotation to 70 degrees. The MEB n arrative s ummary (NARSUM) exam approximately 10 months prior to separation documented that the CI’s left hip had progressively worsened over the prior 3 years and symptoms were exacerbated by climbing and heavy lift ing. The examiner noted that a magnetic resonance imaging ( MRI ) performed in June 200 0 was essentially unremarkable. The examiner opined that although the CI gave a history of an acetabulum fracture of both hips, there was no civilian documentation to support this and assessed the condition as chronic bilateral hip pain . The MEB NARSUM exam findings are summarized in the chart above. The c ommander’s s tatement noted that the restrictions of no marching, jumping, squatting, climbing, heavy lifting bending or stooping limited the CI performing the duties required of her MOS. An MRI of the left lower extremity indicated a benign soft tissue lesion in the left upper thigh. The VA Compensation and Pension (C&P) exam approximately 4 months after separation, noted pain in bilateral hips with flexion. This examination also noted the condition was aggravated by airborne operations and repeat injury. The C&P exam findings are summarized in the chart above.

The Board directs attenti on to its rating recommendation based on the above evidence . The PEB coded the chronic bilateral hip pain 5099-5003 arthritis, degenerative (hypertrophic or osteoarthritis) and most likely invoked the USAPDA pain policy for its 10% rating, considering American Medical Association pain guidelines and reflecting the effect of the chronic pain on bilateral hip function. The VA selected the more specific code 5299 analogous to 5252 but could not achieve service-connection based on the C&P findings (absence of evidence documenting the condition that had existed prior to service had been permanently aggravated by service). The CI appealed and the condition underwent a de novo review. The decision review officer VARD in August 2004 determined the left hip condition was service - connected and rated the left hip disability as 5010-5252 at 10% effective the day after separation from service . In 2012 , the VA service - connected the CI’s right hip condition . The VARD in July 2012 rated the right hip disability as 5252 at 10% , effective the day after separation . The MEB exam noted progressive left hip wo rsening; however , the physical exam findings indicated bilateral tight hamstrings and limited straight leg raises along with a diagnosis of chronic bilateral hip pain. The Board cannot explain why the VA did not consider the findings of bilateral painful motion on adduction and bilateral pain on flexion which certainly contributed to a functional impairment and did not apply §4.59 (painful motion). Th e Board agreed that the more probative evaluation reflecting disability at separation was that of the VA examination with application of §4.59 . This examination clearly warranted application of VASRD § 4.59 to achieve the minimal compensable rating (10%). After due deliberation, in consideration of the totality of the evidence, a majority of the Board concluded that the right and left hip pain were each separately unfitting and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a for the chronic left hip pain and 10% coded 5099-5003 IAW VASRD §4.71a for the chronic right hip pain.


 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 the c hronic b ilateral h ip p ain condition was likely operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic bilateral hip pain condition, the Board, by a vote of 2:1, recommends that each joint be separately adjudicated as follows: an unfitting chronic right hip pain condition coded 5099-5003 and rated 10%, and an unfitting chronic left hip pain condition, coded 5099-5003 and rated 10%, both IAW VASRD §4.71a. The single voter for dissent (who recommended a determination that while the left hip was separately unfitting, the right hip was not, and who therefore recommended an overall rating of 10%) 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
Chronic Left Hip Pain
 5099-5003 10%
Chronic Right Hip Pain
 5099-5003 10%
COMBINED (w/ BLF)
 2 0%
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The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 111121 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans ’ Affairs Treatment Record




Physical Disability Board of Review


SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB ),


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130010252 (PD201101093)


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 20% 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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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