RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02634
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, IT Specialist, medically separated for “right hip degenerative disc disease” and “left hip dysplasia with degenerative joint disease [DJD],” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contends for his not unfitting right knee which is getting worse.  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 - 20090626	VARD - 20091119	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Hip Dysplasia with DJD	5010-5251	10%	Right Hip Dysplasia	5010-5251	10%	20090327	
Left Hip Dysplasia with DJD	5003-5251	10%	Left Hip Dysplasia	5003-5251	10%	20090327	
DJD Right Knee	Not Unfitting 	DJD Right Knee	5010	0%	20090327	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Right and Left Hip Dysplasia with DJD.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented an onset of the condition in 2005 with right hip pain following a fall.  Imaging (multiple X-rays and magnetic resonance imagings) noted degenerative changes with additional findings suggestive of avascular necrosis (AVN, area of dead bone from poor blood supply) or dysplasia.  The condition was treated conservatively (with conflicting orthopedic opinions regarding the presence of AVN), and the CI eventually developed pain (less severe) in the left hip.  Surgery on the right hip (periacetabular osteotomy) was performed in July 2008, 16 months prior to separation, with no available evidence indicating the presence of AVN.  The symptoms improved post-operatively, but not sufficiently for retention.  The left hip pain persisted, with imaging findings similar to those for the right, but no surgical intervention was undertaken.  Post-operative outpatient STR entries document a good recovery, normal gait, and range of motion (ROM) measurements commensurate with those presented below.
  
A VA Compensation and Pension (C&P) examination in March 2009, performed 7 months before separation, documented “no current left hip pain,” but constant right hip pain rated 8/10; with listed functional impairments of “no running, difficulty walking in a straight line, and bending.”  The VA physical examination recorded a normal gait, joint tenderness on the right but not on the left and normal bilateral strength without atrophy.  The VA measured ROM was right flexion to 95 degrees (accommodating De Luca deduction of 6 degrees) and left flexion to 120 degrees (normal 125, 45 for minimum 10%), right and left extension to 20 degrees (normal), external rotation to 25 degrees right and 45 degrees left (normal 45, 15 for minimum 10%), abduction to 20 degrees right and 25 degrees left (normal 45, 10 for minimum 10%), and adduction to 45 degrees right and 25 degrees left (normal 45, “cannot cross legs” [~10 degrees] for minimum 10%).

The NARSUM was conducted 14 April 2009, 2 weeks after the C&P examination, and stated, “The soldier did fairly well after surgery; however, he continues to have pain, sharp at times, and also complaining of left hip pain.”  The only documented functional limitations were profile restrictions.  The NARSUM physical examination was taken from the above VA examination.

The Board directed attention to its rating recommendations based on the above evidence.  The PEB’s separate 10% ratings (coded as arthritis rated for limitation of hip extension, identical to the DoD/VA Pilot VA ratings) were consistent with VASRD §4.71a criteria for the Service ROM evidence (conceding painful motion) and other ratable findings.  There was no ROM limitation, ankylosis, fracture deformity, flail joint or instability, or nonunion/malunion that would achieve a rating higher than 10% for either hip under any alternate code.  The Board considered whether a higher rating under analogous application of 5255 (femur code with contiguous hip disability) could be fairly recommended, but members agreed that the functional evidence at separation (normal gait, documented limitations) was not reasonably consistent with moderate or greater disability for either hip.  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 and left hip conditions.

Contended Right Knee.  The C&P examination documented a 2004 onset of right knee pain with running.  The only relevant entry in the available STR was a 2006 (3 years prior to separation) complaint of right knee pain which documented a normal examination and conservative treatment.  The condition was never profiled in service.  The NARSUM included “right knee arthritis” with the medical history, and provided no additional evidence.  The condition “early DJD [degenerative joint disease], right knee” was forwarded to the MEB as meeting retention standards.  The commander’s performance statement, dated a month earlier than the NARSUM, implicated only “right hip surgery” and did not detail any limitations that could not be attributed solely to that condition.

The Board’s main charge is to assess the fairness of the PEB’s determination that the right knee was 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.  The right knee condition was stable without evidence of significant clinical acuity at separation, did not require a profile, did not fail retention standards, and was not implicated by the commander.  Furthermore, it was logically subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance Until Referral); which stipulated, “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.”  Members thus agreed that there was a lack of performance based evidence indicating that the right knee condition significantly interfered with duty requirements.  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 right knee condition and so no additional disability rating is recommended.   

BOARD FINDINGS:  In the matter of the right and left hip conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudications.  In the matter of the contended right knee condition, the Board unanimously recommends no change from the PEB determination 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 20140601, 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

28 JUL 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160007633 (PD201402634)

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