RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00187
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Armament Avionics Systems Repairer, medically separated for “chronic pain in left hip and both knees” and “chronic non-radiating low back pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “Please consider all conditions.”  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 based upon a 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 - 20060807	VARD – 20070830 and 20071101	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Hip and Bilateral Knee Pain	5099-5003	10%	Bursitis, Left Hip	5019-5255	20%	20071101	
			Right Knee Strain	5010	10%		
			Left Knee Strain		10%		
Non-Radiating Low Back Pain	5299-5237	10%	Lumbar Back Strain	5237	10%		
Left Groin Pain	Not Unfitting	No VA Placement	
Left Shoulder Pain			
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:    

Left Hip Pain.  The PEB combined the left hip pain and bilateral knee joint pain conditions as a single unfitting condition coded analogously to 5003 and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 left hip and bilateral knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating, including of the left and right knees, if indicated.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI related the left hip condition to a motorcycle accident in September 2004.  Left hip X-rays in December 2005 noted more than a 1 year history of hip pain since a motor vehicle accident and the X-rays were normal.  At a primary care evaluation in January 2006 for chronic left knee pain, the CI reported chronic left knee and hip pain for over a year, with worsening left hip pain after physical therapy manipulated his hip. There was tenderness to palpation (TTP) over the anterior hip with full range of motion (ROM) and a normal gait.  Orthopedic evaluation for chronic left hip and left knee pain in February 2006 focused on evaluation of the left hip.  Imaging of the hip showed possible hip impingement and cartilage injury/tear.  An orthopedic follow-up visit noted no clear evidence of cartilage injury/tear or impingement.  The orthopedic assessment was hip pain of unclear etiology and a permanent profile was written.  The MEB forwarded “left hip pain” for PEB adjudication.  

The commander’s statement listed the CI’s multiple problems over the past year which included knee, hip, back and shoulder pain, but noted that the physical limitations of the CI’s permanent profile impaired his duty performance.  The permanent profile listed left hip pain and back pain. 

The Board first considered whether the left hip condition, when considered separately from the bilateral knee condition, was unfitting for continued military service.  The Board concluded that based on the evidence above there was not a preponderance of evidence of the service records that overcame the Board’s presumption that the bundled left hip condition was reasonably considered separately unfitting.  The Board then considered its rating recommendation for the unfitting left hip condition at the time of separation.  

The MEB NARSUM examination 14 June 2006, 5 months before separation, the CI reported left hip pain, as well as both knees, and lower back.  The anterior hip pain radiated to the left buttock and was aggravated by activity.  The physical examination showed an antalgic gait.  There was diffuse tenderness of the hip and groin area.  Hip ROM was 120 degrees flexion (normal 125 degrees), abduction of 35 degrees (normal 45 degrees), adduction of 20 degrees (normal 45 degrees) and normal extension and external rotation, with all left hip motion painful.  There was normal muscle strength and the muscles of the left thigh were well developed.  The MEB NARSUM indicated that the CI was undergoing a MEB for left hip pain.  The MEB NARSUM examiner cited daily pain of the left hip, both knees, and low back and determined the CI failed to meet retentions standards in accordance with AR 40-501, Chapter 3, paragraph 3-14.  

At the 5 September 2007 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported left hip pain that radiated to the left low back.  He reported giving way, popping, and locking of the hip.  He related pain was aggravated by activity and relieved by rest and that at the time of pain he could function with medication.  He reported three episodes of incapacitation in the past year.  The physical examination showed a limping gait favoring the left.  He was not using a cane or a crutch.  There was hip TTP and guarding of movement without subluxation, effusion or weakness.  Hip ROM was flexion of 100 degrees, adduction of 20 degrees, abduction of 30 degrees, and normal extension and rotation.  Pain with all ROM movements began at the listed degrees of ROM.  There was no additional loss of ROM with repetition.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left hip and bilateral knee conditions 10%, coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency (USAPDA) pain policy.  The initial VA Rating Decision (VARD) did not address the left hip condition.  The VARD dated 1 November 2007 rated the left hip condition 10% coded 5019-5255 (bursitis - femur, impairment of), based on the VA C&P examination 9 months after separation, citing “mild” hip disability.  

There was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) coded as 5251 (limited thigh extension), 5252 (limited thigh flexion). There was no limitation of motion which supported a higher rating under 5251, 5252, or 5253. There was no evidence of hip ankyloses, flail hip joint, or femur impairment (5250, 5254, 5255) for a rating under the respective codes.  There was therefore no route to a rating higher than 10% under any applicable VASRD §4.71a code.  

Bilateral Knee Pain.  According to the STR and the MEB NARSUM, the CI’s knee pain began in December 2002.  The CI reported left anterior knee pain in August 2004, present since an unidentified trauma in December 2002.  The CI was given an injection for bursitis without improvement.  At a follow-up primary care clinic (PCC) visit, the examination was normal except for positive patellar grind and apprehension tests.  The CI was diagnosed with retropatellar pain syndrome and given a 2 week profile.  In August 2005, the CI reported pain in the left knee for one day after running and also noted right knee pain behind the patella for one year since a motorcycle accident in September 2004.  The examination noted full ROM without effusion, crepitus, or TTP and the CI was given a temporary profile and anti-inflammatory medication for right knee pain.  At a PCC visit on 11 January 2006 the CI reported left knee pain for one year (after September 2004 motorcycle accident) not helped by PT or multiple profiles and medications.  The examination noted a normal gait.  There was no effusion, crepitus or patellar pain.  There was full ROM, no evidence of instability or meniscal injury.  Strength was normal.  Left knee MRI in February 2006 noted some degeneration of the lateral meniscus and was otherwise normal.  The majority of treatment notes in the STR that addressed knee pain noted only the left knee (4/6). The MEB forwarded “bilateral joint knee pain” for PEB adjudication.  

There was a temporary L2 profile for left hip and knee pain dated 11 January 2006.  There was a temporary L3 profile for left hip pain dated 10 March 2006.  A permanent L3 profile dated 17 May 2006 listed left hip pain, back pain, and bilateral knee pain.  The final permanent L3 profile listed left hip pain and back pain.  The commander’s statement indicated that the CI had numerous problems in the past year, including knee hip back and shoulder problems, and that his permanent profile limitations impaired his duty performance.  

The Board considered whether the bilateral knee condition, when considered separately from the left hip condition, was unfitting for continued military service.  Each knee was given a temporary two week profile at the time the CI first sought treatment for first left, then right knee pain.  The bilateral knee condition was listed on a temporary L2 profile (a “2” profile designation indicates a condition which requires some physical limitations, but is not in all cases disqualifying for continued military service), and the bilateral knee pain was not carried over to the permanent L3 profile.  The Board also noted that notes in the STR at times associated the left knee pain (predominate knee pain) with the left hip condition.  Pain from a joint may commonly produce symptoms above or below it due to radiating or referred pain.  There was no definitive diagnosis of either knee confirmed by imaging or the orthopedic specialist.  The MEB NARSUM examiner noted the CI fell below retention standards according to AR 40-501, Chapter 3, paragraph 3-14, which implicates miscellaneous conditions of the lower extremities, in this case arthritis or degenerative changes, which further supports the PEB’s combined adjudication of the hip and bilateral knees IAW VASRD 5003.  Therefore, the Board concluded that there was a preponderance of evidence in record that the bilateral knee condition would not reasonably have caused the CI to be referred into the DES or be found unfit when considered apart from the left hip pain condition.  Therefore, additional disability rating cannot be recommended.  

Having unbundled the left hip and bilateral knee conditions, the Board found there was no ratings benefit to the CI.  The Board deliberations arrived at a 10% rating for the hip as the PEB had provided for its combined adjudication.  The Board also noted that the PEB’s reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating and multiple joints may be rated under 5003 IAW VASRD 5003 rating criteria as noted above.  Therefore, no change to the PEB combined adjudication or coding is recommended.  

Low Back Pain.  According to the STR and the MEB NARSUM, the CI’s back pain condition began in December 2003.  There was no reported injury or trauma.  The NARSUM noted low back pain (LBP) and indicated that left hip pain radiated to the left buttock region and nothing else.  There were scant treatment notes addressing the thoracolumbar (TL) spine in record.  Four visits between 21 June 2006 and 10 August 2006 noted upper left back pain.  At the time the CI was already on a P3 profile and undergoing a MEB and two visits were after the MEB referral to the PEB noted below.  On examination a non-antalgic gait was noted with tenderness of the left trapezius muscle.  On the last visit the CI reported no change in intermittent upper back pain.  The MEB forwarded “low back pain” for PEB adjudication.  

The MEB NARSUM examination on 14 June 2006, 5 months prior to separation, the CI reported LBP.  The physical examination of the TL spine showed a normal appearance with normal spinal curvatures and no muscle spasms.  There was TTP of the left paraspinal muscles.  There was “full function and ROM with pain on flexion greater than 90 degrees” (normal 90 degrees), without neurologic deficits.

At the 5 September 2007 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported constant LBP aggravated by activity.  He reported he could function with medications for the LBP and the condition caused no incapacitation.  The physical examination showed a limp favoring the left.  The CI was not using an assistive device for ambulation. There was radiating pain on movement.  There was TTP without muscle spasm or abnormal spinal contour.  Straight leg raise testing to elicit radicular symptoms was negative.  Thoracolumbar ROM was recorded as flexion of 50 degrees and combined ROM of 150 degrees with pain.  The ROM recorded was at the point the CI reported pain for all ROM measurements.  There was no additional loss of ROM with repetition.  There were no signs of intervertebral disc syndrome.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5237 (lumbosacral strain), citing paraspinal tenderness and full ROM.  The initial VA rating of the back condition was also 10%, coded 5237, based on the service treatment records, citing painful or limited motion of a major joint.  The VARD 1 November 2007 increased the rating to 20% based on the VA C&P examination 9 months after separation.  

The Board agreed that a 10% rating, but no higher, was justified for tenderness and pain with full ROM reported on the MEB NARSUM examination.  Although the ROM recorded at the VA C&P examination 9 months after separation supported a 20% rating, the Board accorded the VA ROM less probative value for two reasons.  First, there was no evidence that TL ROM was ever limited to less than 60 degrees proximate to separation.  Second, it appeared the VA examiner documented the end of ROM as equal to the point at which pain was reported by the CI and TL ROM is supposed to be as far as the CI can move, even if with pain per VASRD guidance.  This is supported by the fact that on the examination there was TTP noted, but no spinal deformity, muscles spasm, radicular symptoms or other examination findings corroborating such limitation of TL ROM.  There was also no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  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 back condition.  

Contended PEB Conditions:  Left Groin Pain and Left Shoulder Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of these conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  As noted above the left groin pain was related to the left hip condition.  There was no evidence of a diagnosed groin condition which could have been considered separately unfitting.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left hip and bilateral knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left groin and left shoulder 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 20150309, 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

19 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018512  (PD201500187)

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
(  ) DVA