RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01365
BRANCH OF SERVICE:  Army	BOARD DATE:  20150310
SEPARATION DATE:  20040821

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve O-4 (Information Systems Operator) medically separated for right wrist, left hip and bilateral knee conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  The CI was permitted to take the Army Physical Fitness Test alternate aerobic portion.  She was issued a permanent P3/U3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded the following conditions to the Physical Evaluation Board (PEB) IAW AR 40-501 as not meeting retention standards:  “osteoarthritis left hip, osteoarthritis both knees, right carpal tunnel syndrome (CTS), mild.”  No other conditions were submitted by the MEB.  The PEB adjudicated the right wrist as unfitting rated 10% citing coding from U.S. Army Physical Disability Agency Policy/Guidance memorandum #12, Table of Analogous Codes; and citing rating criteria from the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB bundled the bilateral knees and the left hip into one condition and determined these combined conditions were not compensable, citing that they existed prior to service (EPTS) without permanent service aggravation beyond natural progression by such service.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Medical records were not forwarded in a timely manner from unit.”

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 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:

Service IPEB – Dated 20040520	VA - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Carpal Tunnel Syndrome	8599-8515	10%	Healed Fracture, Right Radius and Ulnar Styloid	5215-5010	10%	20041103	
			Right Upper Extremity Median Neuropathy	8615	10%	20041103	
Osteoarthritis Left Hip and Bilateral Knees	5003-EPTS	---	DJD Bilateral Hips	5003	Deferred*	
			DJD Bilateral Knees	5003	Deferred**	
Other x 0 (Not In Scope)	Combined:  20%	
Combined:  10%		
Derived from VA Rating Decision (VARD) dated 20050406 (most proximate to date of separation [DOS]).
* VARD 20051207 granted service connection for right hip replacement, degenerative joint disease, coded 5054, rated 30% disabling effective 20040822; left hip replacement, degenerative joint disease, coded 5054, rated 30% disabling effective 20040822, then 100% disabling (temporary total evaluation) effective 20041206, then 30% disabling effective 20060201.  **VARD 20051207 granted service connection for DJD left knee and right knee, coded as 5010, rated 10% each, effective 20040822.
VARD 20070327 granted 100% (temporary total evaluation) for DC 8615 effective 20060223, then 10% effective 20060501.
VARD 20070604 increased DC 8615 to 50% effective 20060501; and granted 0% for right wrist/palm scar (DC 7805) effective 20060223.
VARD 20140619 increased DC 5054 for right and left hip to 50% each, effective 20130827.

ANALYSIS SUMMARY:

Right Carpal Tunnel Condition.  The right hand dominant CI had an open fracture of the right radius and ulna in 1977 while in the Marine Corps.  It was treated with closed reduction and healed well.  A Reserve retention physical dated 4 September 2002 documented a normal upper extremity examination.  The narrative summary (NARSUM) examination, performed on 25 March 2004, 5 months prior to separation, noted “complications throughout the treatment course” after the right wrist reduction.  The physical examination documented thenar atrophy (soft tissue swelling on the radial side) radial deviation of the hand, crepitance with range-of-motion (ROM) testing, 45 degrees of flexion 60 degrees of extension, decreased sensation (2 point discrimination), and positive Tinel’s and Phalen’s test (for detection of irritated nerves/CTS).  A diagnosis of bilateral CTS was rendered and determined to preclude satisfactory performance of duty.  On DD Form 2807-1 dated 24 March 2004, the examiner noted report of right wrist weather sensitivity and dropping things due to decreased strength.  The examiner additionally noted that the CI’s pain symptoms were controlled by managing her activities and that the right wrist had been permanently profiled.  The MEB physical examination evidenced mild right thenar atrophy and mild loss of ROM.  An occupational therapy (OT) note dated 28 April 2004 (4 months prior to separation) documented wrist edema, decreased grip strength on the right (60 pounds) as compared to the left (75 pounds), and radiographic evidence of severe osteoarthritis.  An OT note dated 26 May 2004 (3 months prior to separation) documented pain with motion, normal sensation (2 point discrimination), and the ability to make a full fist.  The therapist opined that there was mild functional deficit especially with weight bearing and heavy lifting.  The CI was referred for an electromyogram (EMG) due to reports of progressive worsening of right hand numbness and weakness.  The EMG performed on 29 July 2002 demonstrated right sensorimotor median nerve neuropathy with signs of decreased nerve conduction (denervation).  

At the VA Compensation and Pension (C&P) examination dated 3 November 2004 , 3 months after separation, the examiner documented a shortened radius, flexion of 70 degrees (normal = 80), extension of 60 degrees (normal = 70), radial deviation of 15 degrees (normal = 20), and ulnar deviation of 15 degrees (normal = 45) and negative Tinel’s testing.  There was 7/10 right wrist pain with repetitive use.  At the VA C&P examination dated 16 March 2005, 7 months after separation, the CI reported pain in her right wrist and some paresthesias (tingling, tickling, pricking, or burning) of the hand.  The examiner documented wrist flexion of 70 degrees), extension of 45 degrees, radial deviation of 10 degrees, and ulnar deviation of 25 degrees, atrophy of the right forearm with a grip strength of 4/5 (normal = 5/5).  There was a slightly shortened radius with deviation of the wrist radially and radiographs showed degenerative joint disease of the wrist.  The examiner further stated “the extent to which, in degrees of possible ROM or joint function is additionally limited by pain, fatigue, weakness or lack of endurance following repetitive use for the … wrist is mild to moderate.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the right CTS as unfitting with a disability rating of 10% for mild incomplete paralysis of the median nerve coded 8599-8515 (analogous to paralysis of the median).  The VA rated the right CTS at 10% coded 8615 (neuritis of the median nerve.

The Board considered whether the evidence supported a higher than 10% rating for the right CTS.  The Board agreed that, IAW VASRD §4.123, neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, most closely approximated the underlying median pathophysiology and functional impairment.  The Board members deliberated whether the evidence met the criteria for mild or moderate impairment.  The records documented crepitance and painful motion, abnormal electrophysiologic studies, and atrophy of the right thenar eminence prior to separation.  There was no evidence of functional impairment due an inability to make a fist or weakened flexion of the wrist for a moderate or severe incomplete paralysis of the median nerve for a higher rating.  There was no compensable deficit in wrist ROM under VASRD code 5125 (wrist, limitation of motion) and the maximum rating would be 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 carpal tunnel condition.

Osteoarthritis of the Left Hip and Bilateral Knees Condition:  The PEB adjudicated the osteoarthritis of left hip and bilateral knees unfitting, but EPTS and not permanently service aggravated beyond the natural progression of the disease.  The conditions, therefore, were not rated and combined as a single disability condition, coded analogously to 5003 (degenerative arthritis).  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44, if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single disability rating from the PEB.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  The evidence for the each condition is presented separately.

Left Hip Osteoarthritis.  In this case, the physician stated that the left hip was unfitting on the initial retention physical.  The hip was subsequently profiled, failed to meet retention standards, and was implicated by the NARSUM and in the commander’s statement.  Members agreed that the hip should be conceded as separately unfitting.

At retention physical dated 4 September 2002, the examiner documented a prior history of bilateral hip osteoarthritis, a 2001 right hip replacement, and noted “decreased ROM left hip” (no measurements were documented).  A diagnosis of left hip degenerative joint disease (DJD) was rendered and the examiner referred the CI to Orthopedic surgery for a profile or possible medical board.  A permanent L3E2 profile was issued on 29 October 2002 for DJD right hip status post total hip replacement and the CI was activated on 3 January 2003.  An orthopedic evaluation dated 8 March 2003 noted that the CI was deployed to Corpus Christi and that the CI had severe osteoarthritis of the left hip, but was without complaints.  The physical examination demonstrated slight tenderness to palpation of the left greater trochanter, left hip flexion to 90 degrees, and extension to 60 degrees.  The examiner noted that the severe left hip DJD would most likely require a future replacement.  The orthopedic surgeon determined that based on history and physical examination the left hip DJD did not prevent the CI from performing her current duties and that the CI remained deployable.  An orthopedic note dated 27 January 2004 documented acute on chronic exacerbation of left hip pain which returned to baseline levels.  The examiner noted that the CI was informed of the natural progression of the left hip DJD and that the CI would seek a left total hip arthroplasty after discharge from the military.

The NARSUM 5 months prior to separation, stated that the CI was diagnosed with osteoarthritis about 10 years prior, had already had a right hip replacement, and was scheduled to have a left hip replacement which was delayed due to her deployment.  The CI stated that the left hip caused her significant pain during the deployment, particularly while she performed her duties negotiating stairs and sitting for long periods caused stiffness.  The pain interfered with sleep, increased with length of standing, and caused significant pain for one day after walking the APFT.  The examination documented no pain with ROM and log rolling.  Left hip flexion was 85 degrees (normal is 125 degrees) and external rotation on the left was 5 degrees (normal is 45 degrees).  Radiographs revealed advanced osteoarthritis with loss of joint space.  A diagnosis of left hip osteoarthritis was rendered and determined to preclude satisfactory performance of duty.  At the MEB examination, the CI reported that she was taking anti-inflammatory medications for her osteoarthritis and needed a total hip replacement in the near future.

At the VA C&P examination dated 16 March 2004, 7 months after separation, the CI reported left hip replacement surgery in December 2004.  She reported pain in her hips with weather changes and that her disability affected her walking capacity.  Examination documented a “negative Trendelenburg,” bilateral hip flexion of 110 degrees, and “the extent to which in degrees of possible ROM of joint function is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use for the hips is moderate.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left hip osteoarthritis as unfitting, but found compelling evidence to support a finding that the hip condition was EPTS; was not permanently aggravated beyond natural progression by such service; coded 5003 (degenerative arthritis) and not rated.  The VA initially deferred a rating under 5003, but later granted service-connection with a 30% disability rating; coded 5054 (hip replacement, prosthesis).  Board members agreed that the evidence supported that the left hip osteoarthritis condition was separately unfitting.

The Board then considered the PEB determination that the condition had EPTS and was not permanently service aggravated.  A presumption of service aggravation may only be overcome by competent medical evidence (with such evidence based upon accepted medical principles as opposed to medical opinion) establishing by a preponderance of medical evidence that the natural progression of a pre-existing condition was unaltered by any consequence of military service IAW DOD 1338.32 E3.P4.5.2.3.  The Board noted the Reserve retention examination documented severe osteoarthritis of the left hip with limited ROM prior to activation.  A permanent profile was executed for the right, but not the left hip, prior to deployment.  A post-deployment orthopedic evaluation determined that the CI was able to perform her duties despite the left hip condition.  There was evidence of an acute exacerbation during deployment; however the CI reported, post-deployment, that her pain had returned to baseline.  The Board determined that the left hip osteoarthritis was EPTS.  The medical literature supports the natural progression of this condition and the STR does not highlight any one event that may have aggravated the hip condition or hastened the condition’s rate of natural progression.  The Board recognizes that a total hip arthroplasty was planned prior to activation, postponed for deployment, and performed 4 months after separation; however it would be overly speculative to associate worsening or permanent aggravation of the condition with deployment.  The Board agreed, therefore, that based on the evidence, it could be said with a greater than 50% probability that the condition was not permanently aggravated or accelerated by the CI’s military service, but was related to the natural progression of the disease process.  After due deliberation in consideration of the preponderance of the evidence, members agreed that there was insufficient cause to recommend a change in the PEB’s determination that the left hip condition EPTS and was not permanently aggravated by service.

Bilateral Knee Conditions:  The STR documented a right knee injury that initially occurred during high school.  The CI had no problems until on active duty in August 1985, after she fell into a cement ditch and then “felt her knee cap slip out of place” during a low crawl maneuver.  She reported three patellar dislocations.  The orthopedic examiner documented EPTS and profile limitations were recommended.  The retention physical examiner noted a past medical history of osteoarthritis of the knees upon activation.  At a visit with an orthopedist 8 months prior to separation, the CI reported mild activity related pain in her knees and took anti-inflammatory medications for pain.  The examiner noted right and left knee ROM of 0-120 degrees (normal is 140 degrees), without effusion or tenderness to palpation.  Radiographs documented tri-compartmental DJD.  The NARSUM noted that the knee pain was insidious in onset.  Examination of the right knee revealed no effusion, no pain with motion, and no findings of meniscal or ligamentous instability (with Lachman and McMurray examinations).  Examination of the left knee revealed a 1+ effusion and pain with performing the McMurray’s maneuver on the left, but no findings of meniscal or ligamentous instability.  Radiographs documented bilateral evidence of medial and lateral osteophytes and mild decrease of joint space medially.  At the MEB exam, the CI reported having a permanent profile for her knees and that the pain symptoms could be controlled by managing her activity.  The MEB physical exam documented “clicking over the lateral plateaus of both knees and good ROM bilaterally.  At the VA C&P exam performed 7 months after separation, the CI reported that her knees began giving her problems with swelling in 1985-6 with the right patellar dislocation.  The right knee was scoped in 1990 and found to have a “patellar problem” for which patellar relocation was done.  The CI denied locking but reported that the knees did swell and give way, and that “stairs are a problem.”  The examiner documented a bilateral ROM of 0-135 degrees (normal 0-140 degrees), tenderness under the right patella (less than on the left knee), minimal swelling, no deformity, no instability or ligamentous laxity, and that “the DeLuca classification as the extent to which in degrees of possible ROM of joint function is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use for the knees is moderate.”

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered if either knee condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting.  Members agreed that, based on the evidence, there was questionable basis for arguing that either knee was separately unfitting.  In this case, the osteoarthritis of the knees did not specifically disqualify her from service at the Reserve retention physical but were profiled 5 months prior to separation.  The NARSUM examiner included both knees as having osteoarthritis, but did not state that the knees specifically failed to meet retention criteria.  Neither the STR nor physical findings documented by the MEB examiners supported any functional limitations of the knees.  The unit commander’s statement was not in evidence; however the Medical Hold Company Commander stated that the CI could not perform her duties citing “limitations of her profile and medical conditions.”  The PEB determined her knee conditions to be EPTS and not permanently aggravated beyond the natural progression by military service.  After due deliberation, members agreed that the evidence did not support that the bilateral knee condition could be reasonably justified as separately unfitting resulting in the CI’s inability to perform her MOS. Furthermore, this condition EPTS and the preponderance of evidence overcomes a determination that this was or can be considered service aggravated.  Thus, the Board cannot recommend a separate service rating for this 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 carpal tunnel condition, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left hip condition, the Board unanimously recommends no change in the PEB adjudication that the condition was unfitting, but EPTS and was not permanently aggravated by service; therefore not compensable.  In the matter of the osteoarthritis bilateral knees condition, the Board unanimously determined that neither knee was separately unfitting and that the condition EPTS and was not permanently service aggravated; therefore not compensable.  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 20130911, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXX, AR20150011040 (PD201301365)

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		
						         
CF: 
(  ) DoD PDBR
(  ) DVA