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AF | PDBR | CY2012 | PD2012 01017
Original file (PD2012 01017.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE NUMBER: PD12 0 1017
BRANCH OF SERVICE: Army   BOARD DATE: 2013 0724
Separation Date: 20020925


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (71G10/Patient Administration Specialist), medically separated for displaced stress fracture of the right hip. While at Basic Training CI noted right groin and hip pain for which she presented to the Consolidated Troop Medical Clinic and was evaluated. Despite crutches, closed reduction percutaneous fixation right femoral neck fracture surgery, orthopedics consult, non-steroidal anti-inflammatory drugs (NSAIDs), and a 6-week convalescent leave, the CI failed to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent L3 and referred for a Medical Evaluation Board (MEB). The MEB forwarded right femoral neck stress fracture that was displaced to the Physical Evaluation Board (PEB). The MEB forwarded no other conditions for PEB adjudication. The PEB adjudicated the displaced stress fracture of the right hip condition as unfitting, rated 0%. The CI made no appeals and was medically separated.


CI CONTENTION : “Over the last ten years pain related to the injury has increased. I suffer from stiffer joint movement and flexibility as well as persistent pain from the affected hip.”


 SCOPE OF REVIEW : The Board wishes to clarify that the scope of its review as defined in 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 displaced stress fracture of the right hip condition as requested for consideration meets the criteria prescribed in DoDI 6040.44 for Board purview; and is addressed below, in addition to a review of the Service ratings for the unfitting condition. Any conditions or contention either not requested in this application or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for the Correction of Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20020911
 VA (~1 Mo. Post-Separation) – All Effective Date 20020926
Condition
 Code Rating Condition Code Rating Exam
Displaced Stress Fracture of the Right Hip 5099-5003 0% Residuals of Right Femoral Neck Stress Fracture, Status Post Repair 5255 20%* 20021214
↓No Additional MEB/PEB Entries↓
 Not Service-Connected x 3
Combined: 0%
 Combined: 20%
* Initial VARD 20030207 rated as 5252 at 10% based on hip flexion limited to 40 degrees. However, upon review of the same VA C&P examination, a Decision Review Officer Decision 20040123 assigned a 20% rating for 5255 based on malunion of the femur with moderate knee or hip disability effective the day after separation .


ANALYSIS SUMMARY : The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System fitness determinations and rating decisions for disability at the time of separation. The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Displaced Stress Fracture of the Right Hip Condition . There were 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.

“
Right Hip (Thigh) ROM in Degrees
 After Hospital
Convalescent Leave
~3 Mos. Pre-Sep
 MEB ~1.4 Mos. Pre-Sep VA C&P ~2.5 Mos. Post-Sep
Flexion (0-125⁰)
 110 Full ROM
(Relative to Contralateral Hip)		 40
Extension (0-20⁰)
 15
External Rotation (0-45⁰)
 45 (50) 40
Internal Rotation (0-45)
 30 10
Abduction (0-45⁰)
 45 (60) 20
Adduction (0-45⁰)
 40 15
Comment
 No pain with extremes of motion; walking full weight bearing without pain; ambulating without pain; no pain medication given No pain with extremes of internal or external rotation; no pain with palpation of groin region
DD2808 (20020816): Good ROM; minimal pain over right hip		pain remains constant;”
§4.71a Rating
0%
 0% 20% (Initially 10%)
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The CI developed right groin and hip pain after 6 weeks of basic training and was seen in acute medicine. The examiner diagnosed right quad strain and advised to take an NSAID (Naproxen). Ten days later, the CI had an episode of sudden severe pain in the right hip and she fell to the ground unable to ambulate. She was taken via ambulance to the emergency room, where orthopedics determined that because there was a displaced fracture of the right femoral neck and a high probability of avascular necrosis and malunion, surgical intervention in the form of a closed reduction with percutaneous fixation of right femoral neck stress fracture was performed. The CI was placed on hospital convalescent leave for 6 weeks and a narrative summary (NARSUM) completed upon discharge from this period of convalescent leave on 27 June 2002 noted the CI was ambulating with full weight bearing without any pain. No pain medication was issued at this discharge from hospital convalescent leave. The physical examination findings at discharge from hospital convalescent leave are noted in the chart above. The CI was then placed on unit convalescent leave and the MEB was initiated when unit convalescent leave ended. At follow-up from unit convalescent leave in August 2002, the CI did not have pain. The MEB NARSUM exam approximately a month prior to separation indicated that the CI was asymptomatic. The examiner opined that if the CI resumed her vigorous military training that she would become symptomatic and would be at risk for the development of further stress fractures. The MEB NARSUM physical exam findings are summarized in the chart above. Right hip and pelvis X-rays from June 2002 documented the right femoral head remained viable, the presence of three screws without evidence of joint space violation or failure, and sclerosis along the compression side. The examiner opined that although the CI was currently asymptomatic, she would likely become symptomatic and would be at risk for developing further stress fractures if she were to resume vigorous military training. The physical examination recorded on the DD Form 2808 was completed by a different physician a day after the MEB NARSUM examination and it noted minimal pain. The CI was given a permanent L3 profile for displaced right femoral neck fracture status post fixation with no running, marching, push-ups, no sit-ups, and no carrying a backpack. The Board was unable to obtain a copy of the commander’s statement. The VA Compensation and Pension (C&P) examination approximately 2 months after separation indicated that the CI had essentially recovered well from the surgery but she had continued pain, decreased ROM, and pain upon awakening and with initiating walking at first and then constant pain throughout the day. She was not engaging in running or exercising because this was too painful. She was not taking any pain medication at the time of the examination. The CI was noted to be currently employed but the type of job was not documented. The C&P exam findings are summarized in the chart above. Left hip ROM was also measured and these were normal or exceeded normal for all except for adduction and internal rotation, which were both less than normal. A right hip X-ray showed some sclerosis in the mid femoral neck medially.

The Board directs attenti on to its rating recommendation based on the above evidence . The PEB coded the d isplaced s tress f racture of the r ight h ip condition as analogous to 5003 a rthritis, degenerative (hypertrophic or osteoarthritis) rated 10% stating “rated as analogous to degenerative arthritis without loss of joint motion . ” The VA initially rated the r esiduals of r ight f emoral n eck s tress f racture, s tatus p ost r epair condition as 5252 t high, and limitation of flexion of at 10% based on f lexion limited to 4 0 degrees . However, upon review of the same December 2002 C&P examination, and with no other information, t he VA Decision Review Officer (DRO) changed the Veterans Affairs Schedule for Rating Disabilities ( VASRD ) code to 5255 f emur, impairment of and increased the rating to 20% for moderate hip disability with the same effective date. Th e DRO opined the pain and loss of ROM noted in the chart above produced moderate hip disability. At the time of the MEB NARSUM, the CI was pain free and although actual ROM measurements were not recorded, had full , or near full ROM in the right hip. By the time of the C&P exam a fter separation, the CI ’s condition had worsened and she was found to have continued pain, decreased ROM, pain upon awakening and with initiating walking at first , and then constant pain throughout the day. The Board adjudged that the MEB examination was both closer to and prior to separation and therefore had the higher probative value. After due deliberation, considering all of the evide nce and mindful of VASRD §4.3 ( r easonable doubt ) the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the d isplaced s tress f racture of the r ight h ip 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. In the matter of the d isplaced s tress f racture of the r ight h ip 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
Displaced Stress Fracture of the Right Hip 5099-5003 0%
COMBINED
 0%
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The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 120612 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans ’ Affairs Treatment Record




P hysical Disability Board of Review
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SFMR-RB                                                                         


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


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130018150 (PD201201017)

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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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