RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXX BRANCH OF SERVICE: Army

CASE NUMBER: PD1101056 SEPARATION DATE: 20090227

BOARD DATE: 20121016

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PVT/E-2 (68W/Trainee), medically separated for right femoral neck stress fracture and left sacroiliitis with referred pain to the hip. The CI complained of bilateral atraumatic hip pain. A bone scan revealed a right femoral neck stress fracture. Despite aggressive physical therapy (PT), crutches narcotic and non narcotic medications, the CI failed to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. The CI was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded right hip pain secondary to femoral neck stress fracture and left sacroilitis condition on the DA Form 3947 to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. Adjustment disorder condition, identified in the rating chart below, was also identified and forwarded by the MEB as a medically acceptable condition. The PEB adjudicated the right femoral neck stress fracture condition and left sacroiliitis with referred pain to the hip condition as unfitting with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD), rated 10% and 10% respectively. The CI made no appeals, and was medically separated with a 20% disability rating.

CI CONTENTION: “Not all my medical conditions were considered.”

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in the 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 ratings for unfitting conditions will be reviewed in all cases. The right femoral neck stress fracture and left sacroiliitis with referred pain to the hip conditions requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview, and are accordingly addressed below. The adjustment disorder is not a condition constituting a physical disability and is not compensable IAW DoDI 1332.38, Encl 5 and will not be addressed below. The remaining conditions rated by the VA at separation and listed on the DA Form 294 application are not within the Board’s purview. 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.

RATING COMPARISON:

ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. However the Department of Veterans’ Affairs (DVA), operating under a different set of laws (Title 38, United States Code), is empowered to compensate service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time.

Right Femoral Neck Stress Fracture Condition. 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.

The CI has a well documented history of right hip pain in the service treatment record (STR) starting in September 2008 through to October 2011. The CI was first seen for hip pain in September 2008 with exam findings of right hip TTP and pain with flexion, adduction and internal rotation along with tenderness with ambulation. A hip X-ray done at that time was negative. A bone scan done one week later demonstrated low grade stress fracture of the right femoral neck. The CI was seen in PT for worsening right hip pain with positive Obers test, FABER test, FADIR, Scour test, and Thomas test. The PT note in indicated that the pain was aggravated by walking, standing, getting up from a chair, bending at the waist and lifting/carrying a rucksack and that the pain was dulled by medication but not relieved. A repeat magnetic resonance imaging (MRI) confirmed the right hip stress fracture. The MEB examination a month prior to separation indicated failed PT with right hip pain and discomfort constantly present and aggravated with activity. The examiner opined that the functional impairment was an inability to move with a fighting load at least two miles; construct an individual fighting position and perform 3 to 5 second rushes under direct and indirect fire; an inability to engage in a standard to alternate APFT event and required additional limitations of no running, jumping or marching, no rucksack or individual body armor; no lifting or carrying more than 20 pounds and no prolonged standing for greater than 30 minutes. The MEB documented pain-limited ROMs as summarized above.

The VA Compensation & Pension (C&P) examination, performed 4 months after separation, documented worsening of the right hip pain and stiffness symptoms with standing, walking and strenuous activity with a moderate functional impairment with daily activities. The pain-limited ROMs are charted above. X-ray was normal.

The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the right femoral neck stress fracture analogous to 5255, Femur, impairment of: With slight knee or hip disability and rated 10%. The VA coded the right hip strain condition as 5252, Thigh, limitation of flexion and rated 10%. The PEB and the VA chose different coding options; however, this did not materially affect the rating. Neither coding is predominating, and all exams were ratable at 10%. 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 right femoral neck stress fracture condition.

Left Sacroilitis with Referred Pain to the Hip Condition: There were two goniometric 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.

The CI’s was first seen for left hip pain in September 2008 with exam findings of TTP and pain with flexion, adduction and internal rotation along with tenderness with ambulation. A hip X-ray done at that time was negative. A bone scan done a week later demonstrated a focal stress change of the left femoral neck without fracture. The CI was seen in PT for left hip pain with a positive Scour test, and positive Thomas test. The Orthopedics consult in
3 December 2008 noted TTP, posterior pain in the SI joint. An MRI done at that time noted no evidence of a left hip stress fracture. An SI joint X-ray was normal. The CI was seen in follow up by Orthopedics for left hip pain in January 2009 with findings of a positive impingement test in the anterior and posterior left hip and it was noted that the more the CI walked, there was more pain. The MEB examination indicated complaints of left hip pain greater than the right hip. The examiner noted complaints of referred pain to the left hip however findings suggested nontenderness over the greater trochanter, posterior hip and within the left groin. Based on symptomotology, the CI was diagnosed with left hip sacroiliitis.

The C&P examination documented increased symptoms, and pain limited ROMs as charted above. A left hip MRI performed in February 2009 demonstrated an anterior superior acetabulum labral tear. The examiner opined that there was a moderate functional impairment with daily activities.

The Board directs attention to its rating recommendation based on the above evidence. The PEB found this left sacroilitis with referred pain to the hip condition unfitting at 10% coded analogously to 5236 (Sacroiliac injury and weakness) which uses the criteria of the general rating formula for diseases and injuries of the spine with application of §4.59 painful motion. The VA coding of the left hip acetabular labral tear condition as 5252 Thigh, limitation of flexion of: Flexion limited to 45⁰, rated 10%; differed from the PEB but did not impact the level of disability rating. Neither coding is predominate, and all exams were ratable at 10%. 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 left sacroilitis with referred pain to the hip 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. 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 right femoral neck stress fracture condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the left sacroilitis with referred pain to the hip 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:

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20111107, w/atchs

Exhibit B. Service Treatment Record

Exhibit C. Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXXX

President

Physical Disability Board of Review

SFMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency

(TAPD-ZB / ), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20120019250 (PD201101056)

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)

CF:

( ) DoD PDBR

( ) DVA