RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01253
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090627

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Military Police, medically separated for “left knee patellofemoral syndrome” and “right hip pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Not all injuries were addressed.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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:  

SERVICE PEB - 20090508	VARD – 20100807	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Patellofemoral Syndrome	5099-5993	10%	Left Knee Patellofemoral Syndrome	5024-5260	10%	20100518	
Right Hip Pain	5099-5003	10%	Chronic Mild Right Hip Strain	5024-5252	10%	20100518	
…Right Mild Neurosensory Hearing Deficit	Not Unfitting	Right Mild Neurosensory Hearing Deficit	6100	NSC	20100429	
		Tinnitus	6260	NSC	20100429	
…Seasonal Rhinitis/Bronchitis	Not Unfitting	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Knee Patellofemoral Syndrome.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in August 2008 associated with a sprain during combative training.  An X-ray series ordered for left knee pain and swelling dated 2 September 2008 was negative and magnetic resonance imaging (MRI) of the left knee on 3 November 2008 was normal.  During the physical therapy appointment on 9 February 2009, performed 4 months before separation, the CI reported knee pain with a severity of 4-8/10 (10 being the worst pain) and locking, but that her symptoms had decreased by 70% with physical therapy.  Aggravating factors included walking, running standing negotiating stairs and performing flutter kicks.  On examination there was tenderness to palpitation (TTP) at the left medial collateral ligament (MCL) and the left medial retinacular (fascia (connective tissue covering muscle) attached to the patella) area.  There was no TTP of the left medial/lateral patella border or the left lateral/anterior knee.  Lachman’s and anterior drawer signs were negative for anterior cruciate ligament (ACL) instability.  Motor strength and sensory functions were intact and the gait was normal.  The McMurray sign was negative for meniscal damage.  The range of motion (ROM) was within normal limits.  At the MEB examination (recorded on DD Form 2807-1) dated 17 February 2009, 5 months prior to separation, the CI reported her (left) “knee locks up every once in a while.”  At the time of the orthopedic clinic appointment on 17 February 2009, performed 4 months before separation, the CI reported her left knee was locking for a few seconds, but that her overall symptoms have decreased by 70% with physical therapy.  However, in spite of doing rehabilitation for 5 months and taking pain medication (tramadol, an opioid-like medication and Vicodin (hydrocodone, a narcotic and APAP (acetaminophen, a pain reliever)), she was unable to return to duty as a result of chronic pain diagnosed as patellofemoral syndrome.  At the time of the physical therapy clinic appointment, for the MEB ROM on 9 March 2009, performed 4 months before separation, the CI reported pain localized in the (left) knee.  On examination Lachman’s test was 1A indicating no ACL instability and a posterior drawer test was negative indicating no PCL instability.  Her gait was within normal limits.  The ROM was flexion 136 degrees (140 degrees normal), reduced to 135 degrees after 3 repetitions, extension was 0 degrees (0 degrees normal) with 2 degrees of hyperextension after 3 repetitions.  Additional functional loss was only due to reported pain.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded left knee patellofemoral syndrome for PEB adjudication.  

At the MEB NARSUM examination dictated on 15 April 2009, the CI reported 6/10 left knee pain which increased to 9/10 when walking, kneeling, running, ruck marching, or carrying her individual body armor.  The MEB physical examination noted the CI was in no acute distress and had a normal gait.  There was no evidence of crepitus, fatigue, instability or lack of coordination.  There was pain noted to the medial joint line on palpation.  Anterior and posterior drawer signs were negative for ACL and posterior cruciate ligament (PCL) instability.  Lachman’s test was negative for ACL instability.  There was a negative meniscal sign along with negative signs of erythema, effusion or popliteal pain.  Motor muscle strength and reflexes were normal.  All reductions of ROM were due to pain.  An MRI on 16 January 2010, performed 7 months after separation, showed no meniscal or ligament tears.  

At the VA Compensation and Pension (C&P) examination on 18 May 2010, performed 11 months after separation, the CI reported constant mild throbbing in her left knee which did pop, gave out and buckled if she tried to run.  She wore a knee brace with activities and complained of weakness.  The physical examination showed a normal gait, sensation was intact and reflexes were normal.  There was no additional evidence in the VA C&P examination, however, the VA rating decision referencing this examination as evidence indicated the ROM was flexion of 140 degrees (140 degrees normal) and extension of 0 degrees (0 degrees normal).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis), citing evidence of painful motion.  The VA assigned a 10% rating using the analogous 5024-5260 code (tenosynovitis – leg, limitation of flexion) based on the VA C&P examination 11 months after separation, citing painful motion or limited motion of a major joint or group of minor joints.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  Therefore, there is no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of ankylosis (5256), recurrent subluxation or instability (5257), meniscal dislocation (5258), limitation of flexion limited to 30 degrees or less (5260), or limitation of extension to 15 degrees or more.  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 left knee patellofemoral syndrome condition.  

Right Hip Pain.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s right hip condition began with an insidious onset 2 months before a clinic visit on 9 February 2009, 4 months before separation.  On 17 February 2009, she reported 4-8/10 right hip pain and grinding.  When she did groin stretches she felt her right hip “lock up.”  Aggravating factors included walking, running, standing negotiating stairs and performing flutter kicks.  On examination her gait was normal and the ROM was normal with pain in the hip flexor tendon area on flexion.  There was no guarding and sensation was distally intact.  Motor strength was 4/5 in the right hip with pain compared to 5/5 in the left with pain.  X-ray studies on 17 February 2009 showed no significant bony or joint abnormalities.  On 3 March 2009 there was pain to the lateral hip on deep palpation and with abduction and flexion of the right leg.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right hip pain/subluxation” for PEB adjudication.  

At the time of the physical therapy appointment for the MEB ROM on 9 March 2009, performed 4 months before separation, the CI reported pain localized in the (right) hip.  On examination there was no muscle atrophy, swelling or deformity.  Hip flexion was 115 degrees on the first effort (125 degrees normal), 110 degrees after 3 repetitions with pain beginning at 109 degrees.  Extension was 7 degrees on the first effort (20 degrees normal), 4 degrees after 3 repetitions with pain beginning at 5 degrees.  The ROM was limited by pain, but did not appear to be limited by fatigue, weakness, lack of endurance or incoordination.  At the MEB NARSUM examination dictated on 15 April 2009, the CI reported grinding achy 7/10 pain which increased to 10/10 during weight bearing activities.  The physical examination showed the CI was in no acute distress with a normal gait.  Motor, reflexes and sensory functions were normal.  There was pain on abduction and adduction, with a limited ROM of flexion of the right leg.  There was no evidence of crepitus, fatigue, instability or lack of coordination.  

At the VA Compensation and Pension (C&P) examination on 18 May 2010, performed 11 months after separation, the CI reported constant right hip pain with flare-ups when standing for 30 minutes or walking for 1 hour or 1 mile.  The examiner noted the condition was not incapacitating and the CI had not been prescribed bed rest in the past 12 months.  The physical examination showed a normal gait.  There was TTP of the trochanteric bursa.  The ROM was extension of 30 degrees (20 degrees normal) and flexion of 125 degrees (normal) with pain on abduction; otherwise, after 3 repetitions there was no loss of excursion due to pain, fatigue, weakness or lack of endurance.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5099-5003 code (degenerative arthritis), for right hip pain citing painful motion.  The VA assigned a 10% rating using an analogous 5024-5252 code (tenosynovitis – thigh, limitation of flexion of) based on the VA C&P examination 11 months after separation, citing painful motion or limited motion of a major joint or group of minor joints.  There is no ROM limitation which supports a minimum rating under the applicable codes; and, there is no ankylosis, fracture deformity, flail joint or instability, or nonunion/malunion that would achieve a rating higher than 10% under any alternate code available in VASRD §4.71a. Application of VASRD §4.59 (painful motion), however, was supported by all exams to achieve the minimum rating (10%) under code 5252 (limited flexion).  After due deliberation, and in consideration 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 hip condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the history of right mild neurosensory hearing deficit and history of seasonal rhinitis/bronchitis 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.  The history of right mild neurosensory hearing deficit and history of seasonal rhinitis/bronchitis conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.   

Right Mild Neurosensory Hearing Deficit.  The CI was noted to have normal hearing on accession to the service and an average hearing loss on the left of -2.5 dB and +6.25 dB from January 2008 to February 2009.  At the VA C&P examination the CI reported difficulty hearing if someone is on her right.  She reported noise exposure from sirens, gunshots, tanks and truck passing by, horns, and yelling.  She reported listening to her music at a loud volume through earphones and she worked on motorcycle and cars.  She wore ear protection on the firing range.

HEARING	EXAM	HCD* ~4 Mo. Pre Sep	VA C&P ~10 Mo. After Sep	
LEFT EAR	Average Hearing Loss	11 .25 dB	6.25 dB	
	Speech Discrimination	-	100%	
	Table VI / VIa	I / I	I / I	
RIGHT EAR	Average Hearing  Loss	11.25 dB	7.5 dB	
	Speech Discrimination 	-	100%	
	Table VI / VIa	I / I	I / I	
§4.85 RATING	Table VII	0%	0%	
(Average hearing loss is the sum of pure tone thresholds at 1000, 2000, 3000, and 4000 Hz divided by four). 
 *Hearing Conservation Data

History of Seasonal Rhinitis/Bronchitis. The CI reported on DD Form 2807-1 dated 17 February 2009, she had breathing problems from the weather, pollen, and seasonal allergies for which she used and inhaler episodically.  The aforementioned was reviewed and considered by the Board.  There was no performance based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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:  In the matter of the left knee patellofemoral syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right hip condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended history of right mild neurosensory hearing deficit and history of seasonal rhinitis/bronchitis 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 20140307, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

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 AR20160007278 (PD201401253)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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