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AF | PDBR | CY2014 | PD-2014-02381
Original file (PD-2014-02381.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2014-02381
BRANCH OF SERVICE: Army  BOARD DATE: 20150311
SEPARATION DATE: 20031214


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Radiation Technician Specialist Trainee) medically separated for pain due to stress fractures. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “right inferior pubic rami stress fracture” and “right inferior acetabular stress fracture” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two other conditions (knee and foot pain) for PEB adjudication. The Informal PEB adjudicated “pain due to stress fractures, right pubic ramus and right inferior acetabulum” as unfitting, rated 10%, c iting application of the US Army Physical Disability Agency (USAPDA) pain policy. The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.


CI CONTENTION: “Consider all conditions.”


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


RATING COMPARISON :
IPEB – Dated 20030926
 VA* - (~3 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Pain Due to Stress Fractures, Right Pubic Ramus and Inferior Acetabulum 5099-5003 10% Residuals of Fracture, Right Inferior Pubic Rami and Inferior Acetabulum 5299-5251 10% 20040225
Bilateral Patella Femoral Pain Not Unfitting Patellofemoral Pain Syndrome, Right Knee 5299-5260 10% 20040225
Patellofemoral Pain Syndrome, Left Knee 5299-5260 10%
Bilateral Foot Pain Not Unfitting Bilateral Pes Planus 5276 0% 20040225
Other x0
 Other x0
RATING: 10%
 RATING: 30%
* Derived from VA Rating Decision (VA RD ) dated 200 40422 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY:

Pain Due To Stress Fractures, Right Pubic Ramus and Right Inferior Acetabulum. The evidence documents that the CI developed right hip/pelvis pain during Basic Training that continued during Advanced Individual Training (AIT). There was no traumatic injury noted and the CI was able to pass her fitness test at the end of Basic Training. During AIT, the pain in her right pelvis continued and a bone scan revealed a right inferior acetabular stress fracture and right symphysis pubis stress fracture. These findings were confirmed by plain film X-rays several days later. The CI was treated by physical therapy (PT) and with rest and non-steroidal anti-inflammatory drugs (NSAIDS). After orthopedic evaluation and continued pain in spite of PT treatment, NSAIDS, and multiple profiles, she was unable to pass her Army Fitness Test; and was entered into the Disability Evaluation System (DES).

The narrative summary (NARSUM) prepared 4 months prior to separation noted she complained of pain with prolonged standing/walking, and any running. The pertinent physical exam findings are summarized in the chart below. At the VA Compensation and Pension (C&P) exam performed 2 months after separation, the CI reported symptoms of pain with weight bearing in the right side of the pelvis. The symptoms described occurred constantly and her functional impairment was pain with weight bearing and she could not run or jog. Plain film X-rays at that time were normal. There were no fractures or boney abnormalities present and the hip and sacroiliac joints were unremarkable. The C&P examiner’s impression was stress fracture by subjectivity. The subjective factors were noted above and there were no objective factors present.

The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Hip (Thigh) ROM (Degrees)
 NARSUM 4 Mos. Pre-Sep C&P Exam ~ 2.5 Mos. Post-Sep
Flexion (125 Normal)
 90 125
Extension (20)
 20 20
External Rotation (45)
 45 45
Abduction (0-45)
 30 45
Adduction (45)
 45 25
Comment
 Pos. tenderness to palpation; Normal strength Normal gait; No tenderness; No painful motion ; Normal right & left pelvis exam
§4.71a Rating
 10%* (PEB 10%) 0% (VA 10%)
*IAW VASRD §4.40 (functional loss)

The Board directed attention to its rating recommendation based on the above evidence. The PEB applied the analogous VASRD code of 5099-5003 (degenerative arthritis) and rated it 10% specifically citing the USAPDA pain policy. The VA applied the analogous code of 5299-5251, (limitation of thigh extension) and also rated it 10% citing, “We have assigned a 10 percent disability evaluation based on your recent VA medical examination which recorded your complaints of pain in the joint while bearing weight and reported a full range of motion which, without weight-bearing, is not objectively painful.” As noted in the ROM chart above, there were no compensable ROM measurements or documented painful motion on either exam. While the 4 months prior to separation NARSUM exam documented a slightly decreased right hip flexion, it was an essentially normal exam. The C&P exam 2 months after separation was essentially normal as well, reflecting the natural history of stress fractures to heal with time and decreased activity. At the time of separation, the CI’s right hip condition was not compensable above the 10% level based on the evidence present for review. Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the pain due to stress fractures, right pubic ramus and right inferior acetabulum condition was appropriately recommended in this case.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that bilateral patella femoral pain and bilateral foot conditions were not unfitting. The Board’s threshold for countering fitness determinations-requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. Both conditions were profiled during the DES process. The bilateral patella femoral condition was noted in the commander’s statement, while the bilateral foot condition was not; and neither condition was judged to fail retention standards by the MEB. All record entries related to the bilateral patella femoral pain and bilateral foot conditions were reviewed and considered by the Board. There was no performance based evidence from the record that either condition significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.


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 hip stress fracture condition was operant in this case and the condition was adjudicated independently of that policy by this Board. In the matter of the pain due to stress fractures, right pubic ramus and right inferior acetabulum condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended bilateral patella femoral pain and bilateral foot conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.
The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140522, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record




XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review



SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20150014458 (PD201402381)


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                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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