RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02386
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040518

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (No Primary Specialty) medically separated for chronic knee and hip pain; migraines; and bipolar disorder.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3L3S3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “right knee chrondromalicia [sic], bilateral hip bursitis, migraine headache with weekly incapacitation and bipolar II disorder” to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded “low back pain” and “chronic pain syndrome consistent with fibromyalgia” as meeting retention standards.  The Informal PEB adjudicated the chronic knee and hip pain as one condition, found unfit, rated 20% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The migraine headache and bipolar disorder were found to have existed prior to service (EPTS) and were not permanently service aggravated (PSA) and accordingly were not compensable.  The low back pain (LBP) and chronic pain syndrome conditions were found to be not unfitting.  The CI made no appeals and was medically separated 

CI CONTENTION:  The CI requested that the Board review all of her conditions.  The 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 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 20040324	VA* - (~15 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Knee and Hip Pain	5099-5003	20%	Bursitis Right Hip	5019-5253	0%	20050820	
			Bursitis Left Hip	5019-5253	0%	20050820	
			Right Knee PFS	5019-5257	0%	20050820	
			Left Knee PFS	5019-5257	0%	20050820	
Migraines	8100	---	Migraine Headaches	8100	10%	20050820	
Bi-Polar Disorder	9432	---	Bi-Polar Disorder	9432	NSC	20050817	
			Posttraumatic Stress Disorder	9411	30%	20050817	
Low Back Pain	Not Unfitting	Low Back Pain	5237	NSC	20050820	
Chronic Pain Syndrome	Not Unfitting	Fibromyalgia	5025	20%	20050805	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3	
RATING:  20%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20051027 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  The PEB combined the chronic knee and hip pain as a single unfitting condition, coded 5099-5003 (analogous to degenerative arthritis) and rated 20%.  This approach by the PEB reflects its judgment that the constellation of conditions was unfitting and that there was no need for separate fitness adjudications rather than a judgment that each condition was independently unfitting.  The Board must first satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself.  For any condition determined to be separately unfitting, the Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a.  Regardless, its recommendations may not produce a lower combined rating than that adjudicated by the PEB.

Chronic Knee Pain.  The CI entered active duty on 16 May 2003.  She was first seen for a left calf contusion (bruise) on 6 June 2003.  She was treated with ice and Tylenol and returned to duty.  She was next seen on 17 June 2003, 11 days later, for a 3-day history of right knee pain, noting that the left side (calf) was now asymptomatic.  She was seen again 3 days later for persistent pain.  She denied a history of falling or trauma.  X-rays were normal and she was treated with medications.  A bone scan on 28 July 2003 showed a stress reaction (but not a fracture) of the left > right lower extremity.  Diffuse uptake near the left knee was noted.  None was specified for the hips or right knee.  This was repeated on 13 August 2003 with similar findings.  However, her pain, right > left, persisted and she was referred to orthopedics where she was seen on 18 September 2003.  Findings were suspicious for a tear of the right medial meniscus (a cartilage cushion on the inside of the right knee joint).  This showed evidence of degeneration of the kneecap cartilage (chondromalacia patella) and OCD (osteochondritis dissecans, a condition which can result from repetitive trauma).  She continued duty restrictions and physical therapy, but had recurrent pain with running, again R>L.  An orthopedic appointment on 18 November 2003 noted that she continued to have bilateral knee and hip pain despite an adequate trial of rehabilitation and recommended MEB.  She had used braces as well as used crutches for non-weight bearing and partial weight bearing to allow healing without resolution of her pain.  At the MEB examination on 25 November 2003, the CI reported right greater than left knee pain since June 2003.  The MEB physical examiner noted pain with two maneuvers not expected to be painful, but made no specific comments on the knees.  The narrative summary (NARSUM) was dictated by the treating orthopedic surgeon and dated 18 December 2003, 5 months prior to separation.  It noted that the CI initially had problems with the right knee in June 2003, then the right hip in July 2003, and the left knee and hip in August 2003.  The examiner commented that the OCD lesion of the right knee was not likely to be the source of her pain and that the stress reactions seen on bone scan were consistent with the activity level of basic and advanced infantry training.  The alignment of her limbs was normal, but the range-of-motion (ROM) was from (-) 5 degrees extension (hyperextension) to 130 degrees flexion.  Diffuse tenderness was present, but the examination was otherwise unremarkable.  No specific diagnosis was made other than pain in multiple joints.  At the VA Compensation and Pension (C&P) examinations performed 15 months after separation, the CI reported that she was working as a hospital clerk and that her daily activities were restricted by her pain. She denied an injury to her knees, but noted pain in both since basic training.  Pain onset was initially in the right knee followed by the left.  On examination, she wore braces on both knees.  Her gait was wide based and unsteady on the fibromyalgia evaluation on 5 August 2005.  However, the muscle development was normal and crepitus absent.  She was noted to weigh 195 pounds and to be in poor condition.  At the general examination on 20 August 2005, the ROM was normal.  The CI had tenderness to pressure over the knee while flexing and also crepitus (abnormal sensation) with motion on the joints examination.  The examination was otherwise normal without signs of inflammation, instability, or meniscal damage.  Pain with motion was not recorded.  X-rays were normal.  On examination of the back, she could heel and toe walk, and normal strength with knee flexion and extension.  She could get on and off the examination table without much difficulty.  She was thought to have bilateral patello-femoral syndrome, a condition associated with misalignment of the kneecap over the knee.  It was also noted that the CI also reported bilateral hip pain, bilateral foot pain, left ankle pain, and low back pain.  The goniometric 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.

Knee ROM
(Degrees)	MEB ~5 Mo. Pre-Sep	VA C&P ~15 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	130	130	FROM	FROM	
Extension (0 Normal)	(-) 5	(-) 5	FROM	FROM	
Comment	Painful motion not documented	Painful motion not documented	Painful motion not documented	Painful motion not documented	
§4.71a Rating	0%	0%	0%	0%	

The Board first considered if the knees were unfitting, either combined or separately, when severed from the hip pain condition.  It noted that the CI typically had minimal findings on examination other than pain with grinding.  Her pain began shortly after beginning basic training.  It was not associated with an acute injury, implying overuse.  However, this would be expected to improve with a reduction in activity.  Multiple bone scans did not show significant uptake in the knees as would be expected with overuse.  The OCD lesion was thought by the orthopedist to be unrelated to the pain.  The MEB forwarded only right knee chondromalacia (degeneration of the cartilage of the kneecap) and only the right knee was listed on the final profile.  Review of the record showed that the majority of the profiles and sick slips were for the right knee without mention of the left.  The Board determined that the evidence supports a finding that the right knee was separately unfitting.  It was listed on the final profile and found by the MEB to not meet retention standards.  The majority of clinical visits addressed the right knee pain without comment on the left.  The Board directed attention to its rating recommendation based on the above evidence.  The ROM obtained on both the PEB and C&P examinations supports a 0% rating.  Neither documented painful motion, signs of meniscal disease, or instability.  The PEB rated the knees (and hips) at 20%, coded 5099-5003 (analogous to degenerative arthritis) using the pain policy.  The VA rated each knee at 0%, coded 5019-5257 (bursitis – other impairment of the knee).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), §4.40 (functional loss), and §4.59 painful motion), the Board determined that a disability rating of 0% for the right knee condition could be supported.  However, this provides no advantage to the CI and no change in the PEB adjudication for the knee condition (right or left) is recommended.  

Chronic Hip Pain.  In addition to the knee pain, the CI also noted bilateral hip pain.  A request for a pelvic x-ray noted a 4 week history of right sided pain; the X-ray, dated 24 July 2003, was normal.  The CI was seen in primary care 2 days later and thought to have a possible right femoral fracture.  The CI was treated in PT over the next few months for right hip pain.  An X-ray on 30 September 2003 was normal.  As noted above, multiple bone scans were not indicative of hip pathology.  Repeat X-rays on 4 November 2003 were also normal.  In PT on 16 December 2003, the CI was noted to have reduced pain after a decrease in activity.  At the MEB examination on 25 November 2003, the examiner noted greater trochanter bursa (a sac to reduce friction near the hip) pain, right > left.  The ROM was noted to be normal.  The NARSUM noted that the CI initially had ROM from 0-120 degrees bilaterally noting that it was limited by pain.  As noted above, the examiner, an orthopedic surgeon, note the absence of a discrete injury and that the bone scan only showed changes expected with the stress of training.  At the VA C&P examinations, the CI reported that she was working as a hospital clerk and that her daily activities were restricted by her pain.  On the fibromyalgia examination, her gait was wide based and unsteady.  Her X-rays were normal and muscle development normal.  At the general examination, the CI reported that the pain was aggravated by activity.  On examination, she was tender over each hip, but had full ROM. Painful motion was not recorded.  The 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.  

Hip ROM
(Degrees)	MEB ~5 Mo. Pre-Sep	VA C&P ~15 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (125 Normal)	120	120	FROM	FROM	
Extension (20 Normal)	0	0	FROM	FROM	
External Rotation (45)	50	50	FROM	FROM	
Abduction (0-45)	No measures	No measures	FROM	FROM	
Adduction (45)	No measures	No measures	FROM	FROM	
Comment	Painful motion	Painful motion	Painful motion not documented	Painful motion not documented	
§4.71a Rating	10% (4.59)	10% (4.59)	0%	0%	

The Board first considered if either the right, left, or both hips were unfitting when decoupled from the bilateral knee pain decision.  It noted that both hips were listed on the final profile and also listed by the orthopedist who dictated the NARSUM.  The MEB determined that the bilateral hip bursitis condition did not meet retention standards.  However, the Board also noted that the clinical records leading up to separation focused on the right hip and were, other than those for the MEB process, silent for a left hip condition.  The Board determined that the evidence supports a finding that the right hip was separately unfitting at separation.  The Board directed attention to its rating recommendation based on the above evidence.  As noted, the PEB combined the hips and knees in to a single unfitting condition.  The VA rated each hip at 0%, using the codes 5019 and 5253 (impairment of the thigh).  A 10% rating for painful motion is supported for the right hip.  However, absent the addition of other ratable conditions, this provides no advantage 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 for the right hip condition.  

Migraines.  The CI was first seen for a headache on 27 May 2003 and reported a 7-8 year history.  She was treated for sinusitis and next seen on 27 August 2003 for a recurrent headache.  In addition, she occasionally had syncopal (fainting) spells with the headaches.  At the MEB examination on 18 November 2003, the CI reported fainting spells, but denied severe headaches.  The neurological examination was normal with 2 signs of non-organic pain.  The commander cited the knee and hip pain as limiting duty, but made no comment on the headache condition.  A brain MRI on 18 December 2003 was normal.  The neurology NARSUM addendum was dated 14 January 2004 and recorded that the headaches had begun approximately 7 months earlier with none since December 2003.  She reported that 1-2 times a week she was disabled from headaches for 6-8 hours.  She also had a history of “spells” 7 times associated with feeling faint and loss of consciousness.  She reported feeling confused for 5 minutes after awakening, but no other signs associated with a seizure.  She also decreased sensation of the left side of the face, arm, and leg with a normal corneal reflex (blinking when touched).  She had an antalgic gait (abnormal due to protection from pain), but a normal arm swing.  Motor function and reflexes were normal.  She was evaluated in neurology on 24 February 2004 and noted to have migraine headaches with atypical fainting spells. A trial of a prophylactic medication was stopped after she developed a rash.  She reported that since starting a medication for her mental health condition (below), the severity of her headaches had decreased even though the frequency remained the same at 4/week.  A repeat MRI on 23 May 2004 was normal other than a congenital variant. An addendum to the MEB on 11 March 2004 noted that the CI had been diagnosed with a common migraine present since basic training in June 2003.  At the VA fibromyalgia C&P examination, the CI reported missing 3-4 days of work a month from migraine headaches.  She was noted to have a wide based, lunging gait and difficulty with heel and toe walking.  Signs of cerebellar disease were present on testing.  Strength and reflexes were normal, but the sensory examination showed increased sensitivity of the neck, between the shoulder blades, and the right hand.  Muscle atrophy was not present.  At the VA mental health examination on 17 August 2005, she reported going to school part time and to have two part time jobs.  The VA general C&P was silent for the migraine condition.  It did note a painful gait, but that she was able to toe and heel walk.  Reflexes and motor examination were normal.  The sensory examination was also intact.  Despite demonstrating limited ROM of her back, she was able to get on and off the examination table without difficulty.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB determined that the migraine condition existed prior to service (EPTS) and was not permanently aggravated by service.  The Board observed that the CI was seen for a headache within 2 weeks of accession and that the initial note recorded a 7-8 year history of headaches.  The Board did not find a preponderance of evidence to overturn the PEB adjudication that the headaches existed prior to service.  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 headache condition.  

Bipolar Disorder.  The CI screened positive for symptoms of depression on 10 October 2003.  She was placed on medications although these records are not in evidence.  At the MEB examination, the CI reported that she had been admitted for a suicide attempt in August 1998 and July 2000.  Neither was disclosed at accession.  She was evaluated in psychiatry on 20 November 2003 and noted to have rapid cycling of her mood, an indication of Bipolar disorder.  She was next seen in mental health on 2 December 2003 and reported that she was stressed due to the ongoing MEB (for the knee and hip pain).  Two days later in psychiatry, the rapid cycling was noted to persist and she was diagnosed with Bipolar II disorder and her medications changed.  On 10 December 2003, she reported that she had been raped over the weekend and had reported this to the authorities.  She denied current significant distress related to the rape, but reported feeling “numb.”  She was diagnosed with post-traumatic stress disorder (PTSD), chronic, with borderline features.  When seen a week later, she reported being upbeat and excited (upcoming pass), but had nightmares from the alleged sexual assault.  She was seen in psychiatry 2 days later and noted to no longer be cycling her mood on the new medication regimen.  She reported some nightmare residuals from the sexual assault.  The CI was seen the next day for a non-emergent command directed mental health evaluation (requested on 12 December 2003).  It was noted that she had depression prior to enlistment.  Her examination was unremarkable and she was in good spirits about being home for the holidays.  She was diagnosed with Bipolar II disorder and noted to be medically disqualified from a mental health perspective.  On 6 January 2004, she reported that she was using her time to get prepared for life after separation and was engaged to be married.  The neurology addendum noted that her sister also had bipolar disorder.  On 15 January 2004 in psychiatry, she was noted to be stable and improved on medications.  Her mental health examination was remarkable for detailing her concerns with her physical symptoms, but she did not endorse nightmares (previously related to the sexual assault).  She was thought to have Bipolar Disorder (most recent episode hypomanic) and that it was an EPTS condition.  The mental health addendum to the NARSUM was dated 18 February 2004.  It noted that the CI initially sought treatment for management of depression and sequelae to a sexual assault.  (The Board noted that the CI was actually already in treatment at the time of the assault.)  She was seen on 27 February 2004 after an overdose of Motrin and Ambien 16 hours earlier.  She denied suicidal ideation or attempt and was not toxic.  She was frustrated that the MEB was taking so long to complete.  The VA fibromyalgia examination was on 5 August 2005.  It noted that the CI reported that she had been raped on active duty, but also sexually abused by a cousin when she was around 8.  At the VA mental health C&P examination on 17 August 2005, the CI reported that she had been treated for depression with an anti-depressant prior to accession, but that this had not been helpful.  She was engaged, going to school part time, and working at two part time jobs.  She was a single mother of a 4-year-old daughter.  On examination, she appeared to be in pain and frustrated with the pain.  She was anxious and somewhat depressed.  She was diagnosed with Bipolar affective disorder and, by history, PTSD.  It was determined that she developed both while in the military.  The PEB determined that the Bipolar disorder was also an EPTS condition and not ratable.  She was thought to show natural progression and not to have permanent service aggravation.  

The Board directed attention to its rating recommendation based on the above evidence.  The CI clearly had pre-existing mental health issues as she had made 2 suicide attempts prior to accession and had been on an anti-depressant, as recorded on the history she prepared for the MEB.  The Board then considered if there had been permanent service aggravation.  The Board noted that the CI was diagnosed with chronic PTSD and noted that she reported being raped the previous weekend.  While rape can precipitate this diagnosis, the symptoms must be present for a minimum of 1 month.  In this case, the incident had been less than a week earlier.  If PTSD was present, then the history of childhood sexual trauma is a more likely cause.  The recent trauma could bring these symptoms to the surface, but the Board noted that the CI denied significant stress from the incident when it was first recorded in mental health.  A week later she reported some nightmares from a sexual assault.  The commander had not commented on any impairment from a mental health condition even though after she had begun treatment with an anti-depressant; however, this assessment was prior to the alleged sexual assault.  At the VA examination, 15 months after separation, she was in school, working, engaged to be married, and a single parent caring for a 4-year-old.  The Board considered the totality of evidence and did not find a preponderance of evidence to overturn the PEB adjudication that the mental health condition was EPTS without permanent service aggravation.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the low back pain and chronic pain syndrome consistent with fibromyalgia 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 back pain was profiled (along with the knee and hip conditions) whereas the chronic pain condition was not.  Neither was implicated in the commander’s statement or judged to fail retention standards.  Both 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 either 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 knee and hip was operant in this case and these conditions were adjudicated independently of that policy by this Board.  The Board noted that separate ratings could be adjudicated for both the right knee and right hip conditions, but that this does not support a higher rating and provides no benefit to the CI.  In the matter of the bilateral knee and hip pain conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the migraine headache and bipolar disorder conditions, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended low back pain and chronic pain syndrome consistent with fibromyalgia 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 20140507, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160004390 (PD201402386)

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 
( ) OVA