RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03139
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070419

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Petroleum Supply Specialist) medically separated for a chronic bilateral hip condition, rated at 10%.  

CI CONTENTION:  The applicant requests the Board consider all conditions.  Her 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 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:

FPEB – Dated 20070103	VA* - (~10 Days Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip Pain	5099-5003	10%	Left Hip Strain	5253	0%	20070409	
			Right Hip Strain	5253	0%	20070409	
Left Shoulder	Not Unfitting	Left Shoulder	5024	10%	20070409	
Right Wrist	Not Unfitting 	Right Wrist	5215	0%	20070409	
Upper Back	Not Unfitting	Thoracolumbar Strain	5237	10%	20070409	
Bilateral Knees	Not Unfitting	Right Knee Strain	5014	10%	20070409	
		Left Knee Strain	5014	10%	20070409	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 10	
RATING: 10%	COMBINED RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20070809 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The Board noted that outpatient VA treatment notes in the record indicated the CI was diagnosed with fibromyalgia (FM) in February 2010 by a VA Rheumatologist.  The Board acknowledges that the multiple joint conditions in the scope of review may have been early manifestations of a FM condition.  However, the Board made note that the scope of its recommendations does not extend to conditions which were not diagnosed in Service, even though symptoms and disability may have been present which were later attributed to such diagnoses.  These undiagnosed conditions cannot be correlated with a fitness determination requisite for Service rating.  The Board will thus evaluate the disability associated with the in-scope conditions, irrespective of Service diagnosis; make fitness recommendations based on functional impact at the time of separation; and, provide rating recommendations for unfitting conditions based on applicable VASRD criteria.

The PEB combined the right and left hip conditions as a single unfitting condition coded analogously to 5003 and rated 10%, with application of the USAPDA pain policy.  The Board also noted that “bundling,” the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the unfitting bilateral hip condition is presented here, with attendant fitness and rating recommendations, if indicated.

Bilateral Hip Pain.  The MEB narrative summary (NARSUM) noted in May 2003, the CI developed bilateral hip pain while deployed, without specific traumatic incident.  Bilateral hip magnetic resonance imaging (MRI) taken on 23 July 2003 noted a focal area of bone swelling in the right hip.  According to the NARSUM the CI was diagnosed with stress reactions of the hips and advised not to return to theater, but at the CI’s request, she completed her deployment.  Notes in the service treatment record indicated following return from deployment, the CI was evaluated by physical medicine and neurology in July 2004.  Lumbar MRI was normal; bone scan and MRI of the pelvis in September 2004 continued to show stress changes of the hips, with no other abnormalities noted.  A Rheumatology evaluation in October 2004 noted abnormal nonspecific laboratory tests consistent with inflammation, but no other evidence of a systemic inflammatory disease, and recommended a P2 profile.  A Rheumatology follow-up on 14 December 2004 noted the CI reported continued hip and groin pain with flexion of the hips and the assessment was “myofascial pain syndrome” and no further rheumatology evaluation was recommended at the time.  Repeat MRI of the hips on 9 May 2006 showed bilateral stress changes, worse compared with the previous September 2004 MRI.  In January 2007, bilateral lower extremity (LE) electro-diagnostic studies and a bone density test (DEXA scan) were normal (no evidence of a neurological problem or osteoporosis).  The CI was treated with various types of physical therapy and was on multiple temporary profiles, but the bilateral hip pain continued and a Medical Evaluation Board (MEB) was initiated.

The DD Form 2808, Report of Medical Examination, dated 21 July 2006, 9 months prior to separation, noted decreased range-of-motion (ROM) of the bilateral hips, with tenderness to palpation (TTP) of the hips and right sacroiliac joint (SIJ), with normal LE strength and sensation.  The MEB orthopedic consultation completed on 9 August 2006, 8 months before separation, noted bilateral hip pain.  The exam noted a normal gait and there was no TTP of the hips.  The right hip ROM was flexion 0 to 75 degrees (normal 125); abduction of 20 degrees (normal 45).  Left hip ROM was flexion 0 to 110 degrees; abduction of 30 degrees; and painful ROM was noted for flexion, abduction, internal rotation and external rotation bilaterally.  Strength, sensation, and reflexes of the LEs were normal.  A P3 profile was recommended, as well as continuation of anti-inflammatory medications and physical therapy.

At the MEB NARSUM exam performed 18 August 2006, 8 months before separation, the CI reported bilateral hip pain.  The exam noted the findings of the MEB orthopedic consult noted above and ROM measured by physical therapy on 24 July 2006.  The PT ROM was right hip flexion of 110 degrees (normal 125); extension 10 degrees (normal 20), abduction 34 degrees (normal 45); external rotation of 15 degrees (normal 45), and full adduction (normal 45), with painful motion noted.  Left hip ROM was flexion of 118 degrees; extension 10 degrees, abduction 24 degrees; external rotation of 11 degrees, and full adduction, with painful motion noted.  All ROM was repeated three times with no additional loss of ROM.

At the MEB Rheumatology consult on 10 January 2007, 3 months before separation, the CI reported the history of hip pain as above and also an episode of the “flu” in mid-2006, associated with aching of all her joints, thought to be an infection, but wrist and shoulder pain continued, right wrist worse than left and left shoulder worse than right and the pain in both joints was aggravated by use.  Bilateral LE pain (thighs, groin) continued at rest and extended into the both calves.  She denied symptoms of systemic inflammatory disease of fevers, ulcers, rheumatoid nodules, etcetera, and was not using any medications.  The exam of the shoulders noted reduced ROM due to pain and bilateral hip TTP and painful motion.  Exams of the elbows, wrists, hands, knees, and ankles were normal.  Laboratory testing showed elevated nonspecific tests, but negative rheumatologic screening tests (rheumatoid factor [RF] and anti-nuclear antibody [ANA]).  The Rheumatologist indicated that the cause of the chronic hip and thigh pain was unknown and suggested some further evaluation, but did not recommend delay of the MEB for further diagnostic investigations.

Duty limitations were recommended by a temporary profile dated 16 December 2004 for hip pain which applied to both LE, including an alternate physical testing event, no running, no flutter kick or leg raises, and no ruck over 2 miles.  The permanent profile dated 14 September 2006 listed limitations due to bilateral hip pain.  The commander’s statement, dated 5 September 2006, specifically noted bilateral hip pain and that the limitations of the CI’s profile prevented her successful performance of the duties of her MOS.

At the VA Compensation and Pension (C&P) exam performed 9 April 2007, less than a month before separation, the CI reported constant hip pain that radiated to the knees, aggravated by activity and stress.  The CI reported she could function with the pain without medication and that the condition did not cause any incapacitation.  The exam noted normal posture and gait.  There was no tenderness, swelling, guarding, or abnormal movement of the hips.  Right and left hip ROM was normal with all motions, with painful external rotation noted.  Normal adduction was noted by therapist and indicated to be to be 25 degrees (normal 45).  There was no additional loss of ROM with repetition.  Bilateral LE exam and hip X-rays were normal.

The Board first considered if the both the right and left hip conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The permanent profile listed both hips, with limitations that applied equally to both hips; the commander’s statement implicated both hip conditions as impairing the CI’s duty performance; and, the CI was treated for both hip conditions, with reported residual chronic pain of both hips.  The Board concluded that evidence supports that both the right and left hips were reasonably considered separately unfitting at the time of separation and eligible for individual ratings.

The Board directed its attention to its rating recommendations based on the above evidence.  The PEB rated the bilateral hip condition 10%, coded 5099-5003 (Analogous to degenerative arthritis), and cited the USAPDA pain policy.  The VA rated the right and left hip conditions 0% each, coded 5253 (Thigh impairment).  The Board agreed that the evidence supports a 10% rating of the right hip and a 10% rating of the left hip, coded either as 5022 (Periostitis) for limited motion according to 5003 rating criteria, or coded as 5299-5252 (Analogous to limited thigh flexion) IAW VASRD §4.59 (Painful motion) and §4.40 (Functional loss), based upon consideration of pain with use and pain with motion of the hips.  The Board reviewed to see if a higher rating was achieved for either or both hips with any applicable code, but at the MEB exam and pre-separation C&P exam, the most proximate exam to the date of separation, there was no evidence of thigh flexion of 30 degrees or less, abduction limited to 10 degrees or less, impairment of the femur (nonunion or malunion), a flail hip joint, or ankylosis to support a higher rating for either hip.  The Board thus determined that the evidence in record supports a 10% rating for each hip and no higher and chose to code the hips 5299-5252.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board majority recommends a disability rating of 10% for the right hip condition and 10% for the left hip condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the left shoulder, right wrist, upper back, and bilateral knee 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.

Left Shoulder Condition.  On the DD Form 2807, Report of Medical History, 9 months before separation, the CI reported left shoulder pain that “comes and goes” and the examiner noted intermittent left shoulder pain for two years which had not been evaluated.  The DD Form 2808 noted full ROM of the bilateral upper extremities (UEs) without TTP.  An X-ray request on 24 July 2006 noted recurrent intermittent left shoulder pain and noted the CI was already in the MEB process.  The MEB orthopedic consultation on 9 August 2006, 8 months before separation, indicated the CI reported left shoulder pain for the past 3 weeks and had not sought treatment for the shoulder pain.  The exam noted normal strength, sensation of the left UE, with equal ROM in the right and left shoulders and one out of five tests indicative of shoulder impingement was positive.  Left shoulder X-rays were normal.  The orthopedic examiner indicated the left shoulder pain condition met retention standards IAW AR 40-501.  The MEB NARSUM noted the CI had a history of left shoulder pain intermittently over the past 2 years.  The NARSUM exam noted the findings of the MEB orthopedic consult noted above.  At a primary care visit on 10 December 2006, the CI reported migrating pain in the shoulders and upper extremities, improved by moderate exercise.  The MEB Rheumatology evaluation on 10 January 2007, 3 months before separation, noted left shoulder pain greater than right, aggravated by use, with painful “decreased” ROM and provided no diagnosis of the shoulder or of a systemic disease involving the shoulder, but recommended further investigation as previously noted.

Right Wrist Condition.  On the DD Form 2807, the CI reported right wrist pain that comes and goes and the examiner noted intermittent wrist pain for more than 20 years.  The DD Form 2808 noted full ROM of the wrist, without TTP.  An X-ray request 24 July 2006 noted recurrent intermittent right wrist pain and noted the CI was already in the MEB process.

The MEB Orthopedic consultation dated 9 August 2006, 8 months before separation, indicated the CI reported intermittent right wrist pain approximately three times per week, aggravated by awkward lifting postures.  She had no previous treatment for the wrist condition.  The exam noted normal wrist ROM with no TTP or evidence of instability.  Right wrist X-rays were normal.  The orthopedic examiner indicated the right wrist condition met retention standards IAW AR 40-501.  The NARSUM noted the CI reported right wrist pain intermittently for over twenty years.  The MEB physical exam noted the findings of the MEB Orthopedic consult above.  As noted above for the shoulder the CI reported migrating pain in the shoulders, wrists, and hands at a PC visit in December 2006, and the MEB rheumatology evaluation, 3 months before separation, noted right wrist pain greater than left, aggravated by use, with normal exam of the wrist and provided no diagnosis of the wrist or of a systemic disease involving the wrist, but recommended further investigation.
Upper Back Condition.  The MEB Orthopedic consultation 9 August 2006, 8 months before separation, indicated the CI reported a history of upper back pain that had resolved, with current symptoms reported as occasional muscle spasms, without extremity symptoms or other neurological symptoms.  The exam did not address the back and no orthopedic diagnosis was provided for the upper back condition.  The NARSUM noted the CI reported recurrent upper back pain since a remote motor vehicle accident in 1997.  According to the MEB examiner the upper back pain met retention standards.  The MEB Rheumatology evaluation 10 January 2007, 3 months before separation, noted only a past history of upper back muscle spasms.

Bilateral Knee Condition.  On the DD Form 2807, the CI reported bilateral knee pain since her hip injuries and the examiner noted the knees had not been evaluated.  The DD Form 2808 noted normal exam of the bilateral knees.  The MEB orthopedic consultation 9 August 2006, 8 months before separation, indicated the CI reported hip pain that radiated to her knees, but no current knee symptoms.  The exam noted a normal gait.  Bilateral knee exam noted no swelling, or abnormal patellar movement.  There was no evidence of instability or symptomatic meniscal injury and knee ROM was 0-120 degrees bilaterally (normal 0-140).  Bilateral knee X-rays showed “mild” joint narrowing.  No orthopedic diagnosis was provided for the knees.  The NARSUM noted the CI reported chronic bilateral knee pain and the MEB physical exam noted the findings of the MEB orthopedic consult above.  According to the MEB examiner the bilateral knee pain met retention standards.

The left shoulder, right wrist, upper back, and the right and left knee (individually or combined) conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  The Board noted that IAW DoDI 1332.38 E3.P3.3.3, adequate performance until the time the Service member was referred for physical evaluation supports a fit for duty determination, even though medical evidence may indicate 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 the any of the 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 b 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 bilateral hip condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the bilateral hip condition, the Board majority recommends a disability rating as follows: an unfitting right hip of 10%, and an unfitting left hip of 10%, both coded 5299-5252 IAW VASRD §4.71a.  In the matters of the contended left shoulder, right wrist, upper back, 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	RATING	
Right Chronic Hip Pain Condition	5299-5252	10%	
Left Chronic Hip Pain Condition	5299-5252	10%	
COMBINED (w/ BLF)	20%	
The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140625, 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 XXX, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160004046 (PD201403139)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA