RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02098
BRANCH OF SERVICE:  Army	BOARD DATE:  20150227
SEPARATION DATE:  20040227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E-4 (Medic) medically separated for bilateral ilio-tibial band (ITB) syndrome.  This condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The bilateral leg condition, characterized as “bilateral ilio-tibial band syndrome…” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded low back pain for PEB adjudication.  The PEB adjudicated “bilateral ilio-tibial band syndrome (snapping hip)…” as unfitting, rated 0%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Bilateral ilio tibial band syndrome, bilateral hip pain, bilateral knee pain, sleep apnea, gastric reflux, depression.”

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 20031118	VA - (6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Ilio-tibial Band Syndrome (Snapping Hip)…	5099-5024	0%	ITBS Left Lower Extremity… 	5024-5260	10%	20040817	
			ITBS Right Lower Extremity…	5024-5260	10%		
No Additional MEB/PEB Entries in Scope	No Additional VA Entries in Scope	
Combined:  0%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20040901.

ANALYSIS SUMMARY:  The Board’s initial charge in this case was directed at determining if the PEB’s approach of combining the bilateral ITB syndrome condition as a single rating was justified in lieu of separate ratings.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each extremity condition are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was unfitting in and of itself.  Not uncommonly this approach by the PEB reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  Thus the Board must maintain the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Bilateral ITB Syndrome Condition.  The treatment record contained only two clinical documents regarding his unfitting condition prior to separation.  The first document was an incomplete primary care report and the other (Orthopedic consultation) indicated that the CI developed bilateral knee pain since “basic training in 1998.”  He was diagnosed with bilateral ITB syndrome (ITBS; an overuse injury of the knee and thigh, the ilio-tibial band runs from outside of the pelvis, over the hip, down to the outside of the knee).  He failed conservative therapy for pain relief and was referred for an MEB.  At the narrative summary examination (5 months prior to separation) the CI reported the “inability to perform the Army physical fitness test run or walk.  [The CI] is unable to perform his duty as a field medic carrying litters or walking over rough or uneven terrain and is unable to walk for more than one mile without pain or two miles until the pain becomes excruciating.”  The physical examination revealed no swelling, deformity, or laxity of his knees.  There was a “minor degree” of bilateral patellar crepitus.  Range-of-motion (ROM) of the knees was not in evidence.  His hip examination revealed a notable “pop” in the ITB, bilaterally.  His hip ROM was decreased.  His diagnosis was bilateral ITB syndrome with abduction contractures of both lower extremities.  The commander’s statement implicated not meeting MOS requirements due to his current knee conditions.  The VA general medicine Compensation and Pension (C&P) examination performed on 7 April 2004 revealed bilateral painful motion at terminal deep knee bends.  At the VA specialty C&P examination performed on 17 August 2004 (6 months after separation), the CI reported that his hip joints had never bothered him, and that his historical complaint was that of knee pain with ITB syndrome.  Although the examiner stated “no hip disease nor restriction of motion found on examination,” the measured hip adduction of 0 degrees was abnormally decreased.  The goniometric ROM evaluations in evidence the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

 Hip (Thigh) ROM
(Degrees)	MEB ~5 Mo. Pre-Sep
	VA C&P ~6 Mo. Post-Sep
	
	Left	Right	Left	Right	
Flexion (125 Normal)	110	110	125	125	
Extension (20)	30	30	-	-	
External Rotation (45)	45 	45 	“full”	“full”	
Abduction (0-45)	45	45	45	45	
Adduction (45)	‘neutral’	‘neutral’	0	0	
Comment	patellar crepitus;
superior ITB ‘pop’ with ROM 	normal gait	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB bundled the bilateral condition and assigned a 0% rating under an analogous 5024 code (tenosynovitis) whereas the VA separately rated and assigned each lower extremity 10% using an analogous dual code of 5024-5260 (tenosynovitis-limitation of leg flexion).  The Board first considered if the bilateral ITB condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting.

Board members first acknowledged that the totality of evidence included comments, concerns, and or clinical evaluations of the CI’s hips and knees with no overwhelming predominance of impairment to either anatomical site.  There were no unilateral distinctions with regards to clinical features or fitness considerations; therefore, Board members agreed that it would remain pure speculation to conclude that any disability separately confined to either leg would not have rendered the CI incapable of performing his MOS; but, it is also reasonable to surmise that it was the combination of both lower extremity symptoms that rendered him unfit for continued military service.  While there was no evidence of compensable limitation of motion within the hips with regards to flexion and extension, the persistent measurement of either “neutral” or “0 degrees” adduction was supported under 5253 (thigh impairment) indicating “cannot cross legs” at 10%.  The 20% level was not supported in light of normal hip abduction.  Additionally, absent knee abnormalities of ROM, instability, or the history of surgical intervention, Board members also agreed that there were no specific unfitting knee conditions present and therefore, no VASRD knee-related codes were supported in this case.  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 bilateral ITB 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 surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised.  In the matter of the bilateral ITB condition, the Board unanimously recommends a combined disability rating of 10%, coded 5253 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends modifying the case determination as follows, effective the date of medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Ilio-tibial Band Syndrome (Snapping Hip)	5253	10%	
COMBINED (w/ BLF)	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140424, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXX, AR20150013723 (201402098)

1.  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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl		XXXXXXXXXXXXXXX
			Deputy Assistant Secretary of the Army
			    (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA