RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01025
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090227  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Light Wheel Vehicle Mechanic) medically separated for left hip pain, rated at 10%.

CI CONTENTION:  He was not rated for his back or knee conditions.  His complete submission is at Exhibit A.

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 20081110	VA* - (3 Wk. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Hip Pain	5099-5003	10%	Left Hip Impingement,	5252	10%	20090206	
Lumbar Spondylosis	Not Unfitting	Chronic Low Back Strain ...	5239-5242	10%		
Lumbar Disc Degeneration						
Bilateral PFS		PFS, Left Knee	5261	10%		
		PFS, Right Knee	5261	10%		
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 5	
RATING: 10%	RATING:  80%	
*Derived from VA Rating Decision (VARD) dated 20090430 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:    

Left Hip Condition.  The service treatment record (STR) corroborated the history in the narrative summary (NARSUM) of an atraumatic onset of left hip about 4 years prior to separation.  It was managed conservatively, but exacerbated by subsequent deployments.  The CI underwent arthroscopic intervention (trochanteric bursa debridement and illiotibial band release) in March 2007 (22 months pre-separation).  Signs of impingement (“popping”) resolved, but pain persisted, and MEB referral ensued.  Follow-up magnetic resonance imaging (MRI) was normal (noting resolution of previously observed bursitis).  There were numerous STR entries documenting grossly normal range-of-motion (ROM), and ROM measurements at less than 10% rating thresholds.  Physical therapy (PT) measurements of 22 July 2008 (4 months pre-separation and 2 months prior to MEB measurements for NARSUM) were flexion to 115 degrees (normal 125, minimum compensable 45), extension to 20 degrees (normal [minimum compensable 5]), and abduction to 35 degrees (normal 45, minimum compensable 10).  There were sporadic STR entries noting a limp, but numerous ones which documented a normal gait (including all of those approaching separation).

The NARSUM was conducted on 27 October 2008 (4 months pre-separation) and documented pain that was “usually tolerable with medication [anti-inflammatory] unless exacerbated by activity ...flare-up with extensive use, especially walking very much.”  The NARSUM physical examination recorded “antalgic gait due to hip” and a “mildly tender” joint; adding, “Fatigue, weakness, and lack of endurance do not appear to significantly limit functional ability.”  The NARSUM cited PT ROM measurements of flexion to 80 degrees, extension to 10 degrees, and abduction to 45 degrees.  

A VA Compensation and Pension (C&P) examination was conducted on 6 February 2009 (3 weeks pre-separation) and documented “still has pain even at rest, worse on prolonged walking and sitting.”  The VA physical examination recorded a normal gait without commenting on specific joint findings for the hip (generic template responses for joints were negative).  The VA measured ROM was flexion to 120 degrees, extension to 20 degrees, external rotation to 45 degrees (normal), and abduction to 45 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating analogous to 5003 (degenerative arthritis) was consistent with VASRD §4.71a criteria for the Service ROM evidence (conceding painful motion) and other ratable findings.  The VA’s 10% rating under 5252 (limitation of flexion) cited painful motion, and was consistent with the C&P findings and ROM. There is no ROM limitation, ankylosis, flail joint, or instability that would achieve a rating higher than 10% under any alternate code; other than consideration of analogous rating under 5299-5255 (femur, impairment of) which offers ratings for contiguous hip disability: 20% for “moderate” and 30% for “marked.”  Members agreed, however, that the analogous application of this fracture code (with no fracture present) was not sufficiently justified by VASRD §4.20 (analogous ratings) in this case, which satisfies compensable criteria under more applicable joint codes.  Members further agreed that no disability greater than moderate could be supported by the evidence; thus, even if conceded, this rating option would offer no practical benefit to the CI.  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 of the right hip condition.

Contended Conditions (Lumbar, Bilateral Knee).    The CI developed complaints of back pain (no radicular symptoms) and bilateral knee pain during a 2006 deployment to Afghanistan, both managed conservatively.  The STR and NARSUM documented normal or nearly so ROM for the back and knees, the absence of impingement or instability with regard to the knees, and normal neurologic testing with regard to the lumbar condition (electrodiagnostic study was also normal).  There was no Service or VA evidence for significant functional limitations distinct from those attributable solely to the hip.  Both conditions were evaluated, but neither was clinically acute during the MEB period.  The back was added to the hip profile in December 2007 (14 months pre-separation).  The knees were not profiled until the final MEB permanent profile (7 months pre-separation).  The commander’s performance statement did not reference specific diagnoses or differentiate functional limitations attributable to specific orthopedic conditions.  Both conditions were, however, forwarded as medically unacceptable by the MEB.
The Board directed attention to its recommendations based on the above evidence; and, its main charge with respect to these conditions is an assessment of the fairness of the PEB’s determinations that they were not unfitting.  The Board’s threshold for countering Service fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Although the conditions were profiled and judged to fail retention standards, all members agreed that there was no performance based evidence suggesting that either of the above conditions distinctly interfered with duty performance at the time of separation.  They were both chronic conditions having been present for 3 years preceding separation, and they were not clinically acute during the MEB evaluation which was directed at the hip condition.  Furthermore, both conditions were subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance Until Referral); which stipulates, “If the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.”  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 either of them; thus neither can be recommended for additional Service disability rating.

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 left hip condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended lumbar spine and bilateral knee 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.

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 20140223, 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 XXXXXXXXXXXXXXXXXX, AR20160002567 (PD201401025)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA