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AF | PDBR | CY2014 | PD 2014 01017
Original file (PD 2014 01017.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX     CASE: PD-2014-01017
BRANCH OF SERVICE: Air force     BOARD DATE: 20141002
SEPARATION DATE: 20090627


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (3S071/Personnel Craftsman) medically separated for a bilateral hip condition. This condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards. She was never permanently profiled above L1, but was referred for a Medical Evaluation Board (MEB). Snapping hip syndrome [bilateral] was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated the snapping hip syndrome [bilateral] condition as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: The CI elaborated no specific contention in her application.


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. Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20090402
 VA* - Based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Snapping Hip Syndrome [Bilateral] 5316 10% Snapping Hip Condition, Left 5299-5255 0%** STR
Snapping Hip Condition, Right 5299-5255 0%** STR
Other x 0 (Not in Scope)
 Other x 6 (Not in Scope) STR
Combined: 10%
 Combined: 0%
*Derived from VA Rating Decision (VARD) dated 20 100708 (most proxima te to date of separation (DOS))
** VASRD 20110126 increased rating s to 10% effective 20090628 (day after DOS)


ANALYSIS SUMMARY: IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus 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 ratable severity at the time of separation.

The PEB combined the right and left snapping hip syndrome conditions under a single disability rating, coded 5316 (Muscle Group XVI). Although this approach may comply with service policy, the Board must apply separate codes and ratings in its recommendations, if compensable ratings for each condition are achieved IAW the VASRD. If the Board judges that two or more separate ratings are warranted in such cases, it must satisfy the requirement that each “unbundled” condition is reasonably justified as separately unfitting. The Board's initial charge in this case was therefore directed at determining if the PEB's approach of combining conditions under a single rating was justified in lieu of separate ratings. If it is judged that one or more of the combined conditions satisfies the unfitting stipulation from above, separate ratings IAW the VASRD are recommend; although, the Board may not recommend a lower combined rating than that achieved by the PEB’s approach.

Snapping Hip Syndrome Condition. The CI developed bilateral hip pain, not due to injury, in December 2005. Persistent pain interfered with physical training activities and did not respond adequately to physical therapy or medications. Surgical options were considered but not pursued due to uncertainty of beneficial outcome. Radiographic evaluations were normal. A MEB orthopedic evaluation in April 2008 (14 months prior to separation) reported pain that was worse with sit-ups and positional changes. Examination showed an audible and palpable snap from flexion to extension, pain with resisted flexion of each hip, but no pain with internal and external rotation. Gait was not antalgic (no painful limp).

At an orthopedic follow-up assessment on 9 December 2008 (6 months prior to separation) the CI noted an exacerbation of right hip pain a month previously while doing sit-ups; she experienced pain with certain movements (e.g. sit-ups), but reported exercising on a treadmill without any pain and that she was having no pain with weight bearing or after prolonged ambulation. Examination showed no hip tenderness. Pain was present with resisted flexion of the right hip and with extension of the right hip from a flexed position. There was no pain with internal and external rotation. Bilateral hip range-of-motion measurements showed flexion of 120 degrees (normal 125 degrees), external rotation 50 (normal 45), abduction 45 (normal 45) and adduction of 20 (normal 45). Extension was not specified. At the narrative summary (NARSUM) exam on 16 December 2008 the CI reported low grade pain on a daily basis. Pain occurred with sitting, standing and physical activity. She was able to accomplish her daily duties, but could not run and was non-deployable. At an outpatient visit for low back pain on 5 February 2009 (4 months prior to separation), the CI was observed to have a normal gait. At a periodic health assessment on 31 March 2009 (3 months prior to separation), the CI indicated that she was exercising regularly, but that hip pain bothered her every day, depending on the level of her physical activity. On a Report of Medical History (DD Form 2807) on 27 May 2009 (a month prior to separation) the CI reported that her bilateral hip condition “produces pain during certain leg movements.”

A VA C&P exam was performed on 23 April 2010 (10 months after separation) but was not in evidence. As reported by the VA rater on 26 January 2011, that examination showed pain with motion of both hips. An audible popping sound was heard during abduction bilaterally.

The Board directs attention to its rating recommendation based on the above evidence. As previously elaborated, the PEB assigned a combined 10% rating for both hips under the 5316 muscle disability code. The Board must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each disability rating. In this case, both hips were considered to fail retention standards and both were implicated by the NARSUM and in the commander’s statement. Members agreed therefore that each hip should be conceded as separately unfitting. The Board considered the PEB’s muscle coding approach, and agreed that “slight” was the most accurate descriptor of each hip condition; thus a 0% rating was warranted for the each hip using this coding option. However, the Board considered rating under limitation of motion coding pathways IAW §4.71a criteria. Board members agreed that compensable limitation of flexion, external rotation, abduction or adduction was not present for either hip (VASRD codes 5252 (thigh, limitation of flexion) or 5253 (thigh, impairment of); and although measured hip extension was not documented, the normal gait reported after the NARSUM exam was not consistent with compensable limitation of extension (code 5251). Although the VA utilized an analogous 5255 code (femur, impairment of; malunion) in an initial bilateral 0% rating, the Board considered this code a poor clinical fit for the CI’s condition. Finally, Board members debated the application of VASRD §4.40 (functional loss) or §4.59 (painful motion), and concluded that the examination findings in evidence supported a 10% rating on this basis for each hip. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right snapping hip syndrome condition and 10% for the left snapping hip syndrome condition, coded 5299-5253.


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 snapping hip syndrome [bilateral] condition, the Board recommends that it be rated for two separate unfitting conditions as follows: right snapping hip syndrome condition coded 5299-5253 and rated 10%; and chronic left snapping hip syndrome condition coded 5299-5253 and rated 10%; both IAW VASRD §4.71a. 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
Right Snapping Hip Syndrome 5299-5253 10%
Left Snapping Hip Syndrome 5299-5253 10%
COMBINED (w/ BLF) 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140224, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record









                                   
XXXXXXXXXXXXXX
President
Physical Disability Board of Review






SAF/MRB
Dear XXXXXXXXXXXXXX:
         Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-01017.

         After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities. Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay.

         I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force. The office responsible for making the correction will inform you when your records have been changed.

                                                               Sincerely,






 XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency
Attachments:
1. Directive
2. Record of Proceedings

cc:
SAF/MRBR

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