RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00508
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050913

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Multimedia Illustrator, medically separated for “chronic hip, knee, and shin,” with a disability rating of 10%.

CI CONTENTION:  The CI details the conditions have worsened and effect his activities of daily living.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20050809	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Hip, Knee, and Shin Pain	5099-5022	10%	No VA Exam in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:  

Chronic Hip, Knee, and Shin Diagnosis.  The PEB combined the chronic hip, knee, and shin pain conditions as a single unfitting condition coded analogously to 5022 and rated 10%.  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 panel’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 panel 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 panel 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 chronic hip, knee, and shin pain conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic hip, knee and shin pain began in Basic Training with running and marching.  The CI initially noted knee pain with running and marching.  A few weeks later, the CI developed hip and shin pain.  Bone scan in November 2004 showed bilateral femoral shaft stress fractures and “other stress associated changes in the lower extremities…bilateral shin splints.”  The CI was evaluated by orthopedics and a second bone scan in May 2005 showed “interval healing of the left proximal diaphiseal [sic] fracture.  Minimal stress related changes at the right proximal fracture (grade 1).”  The permanent profile dated 22 June 2005 listed bilateral “stress fractures” as impairing the CI’s duty performance.  The CI was unable to perform core soldier tasks and was not MOS qualified.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated June 2005, 3 months prior to separation, the physical examination showed an antalgic gait and pain with internal and external rotation “of hip.”  

The MEB NARSUM examination on 21 June 2005, 3 months prior to separation, noted complaints of daily lower extremity pain aggravated by walking and stairs, with clicking and popping of knees and hips.  The physical examination showed a mildly antalgic gait.  There was no swelling of the knees.  There was pain in the “hip” with internal and external rotation.  There was clicking heard during examination maneuvers and the clicking was reproduced with external rotation of the hip.  Physical therapy measured ROM for the MEB on 20 June 2005.  Right hip ROM (after four repetitions) was flexion of 113 degrees (normal 125), extension of 2 degrees (normal 20), abduction of 21 degrees (normal 45) adduction of 39 degrees (normal 45) and external rotation of 29 degrees (normal 45).  Left hip ROM (after four repetitions) was flexion of 114 degrees, extension of 1 degrees, abduction of 18 degrees, adduction of 39 degrees, and external rotation of 22 degrees.  The MEB NARSUM examiner determined that the CI fell below retention standards because of hip, knee, and shin pain due to stress fractures with a persistent positive bone scan.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic hip, knee, and shin pain condition 10%, coded 5099-5022 (analogous to periostitis), citing full ROM of all joints with tenderness to palpation of the lower legs without swelling.  The panel first considered if the hip, knee, and shin pain conditions having been de-coupled from the combined PEB adjudication, each remained separately unfitting as established above.  The permanent profile listed bilateral leg pain with no discrimination between the hip, knee and shin pain.  The commander’s statement and NARSUM likewise indicated the total effects of the bilateral hip and lower leg stress fractures caused the CI to be unable to perform her duties successfully and to fall below retention standards.  The second bone scan proximate to separation noted continued findings of the upper legs (femur shafts) and did not note any persistent stress changes of the lower extremities.  

In this case, bilateral lower extremity pain was profiled, implicated in the commander’s statement and considered to fail retention standards.  The panel readily agreed that the pain conditions of each lower extremity were reasonably considered separately unfitting.  However, based on the evidence in record there was no way to discriminate the disability effects of hip pain, knee pain, and/or shin pain to support recommending more than a single condition of the lower extremity as unfitting at the time of separation for either lower extremity.  The panel therefore concluded that the right hip, knee and shin pain condition was unfitting and the left hip, knee and shin pain condition was unfitting and the right and left lower extremity (LE) conditions could not be further unbundled.  
The panel first considered its rating recommendation for the right LE pain condition.  There was evidence of painful, limited hip ROM at the MEB NARSUM examination to support a 10% rating coded 5099-5022.  A 10% rating was also supported for limitation of right hip extension to 5 degrees, coded 5299-5251 (limitation of thigh flexion).  There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh flexion or thigh impairment (5252, 5253).  There was no evidence of hip ankyloses or flail hip joint (5250, 5254) for a rating under the respective codes.  There was no evidence of femur impairment (5255) with moderate hip or knee disability for a higher rating under 5255.  The panel also considered if the evidence supported a higher rating than 10% under a VASRD knee code, but there was no evidence of sufficient limitation of knee ROM (5260/5261) to warrant rating under these codes.  There was no evidence of tibial impairment (5262) with moderate knee or ankle disability to warrant a higher rating under 5262.  There was no evidence of any other ratable knee impairment.  Finally the panel considered if rating under any ankle code supported a higher rating than 10%, but there was no marked limitation of ankle ROM (5271) and there was no other ratable impairment of the ankle.  There was therefore no route to a rating higher than 10% under any applicable VASRD §4.71a code for the right hip, knee, and shin pain condition.  

The panel then considered its rating recommendation for the left LE pain condition.  As noted above, there are no distinctions with regards to clinical features between the right and left LE pain conditions.  There was evidence to support a 10% rating coded 5099-5022 due to painful limited left hip ROM or coded 5299-5251 for limitation of extension to 5 degrees at the MEB NARSUM examination.  By the same rating rationale as elaborated above under the right LE pain condition, the panel concluded that there was no higher rating than 10% available under any applicable VASRD code for the left LE pain condition.  There was no knee or ankle impairment to support a higher rating.  There was therefore no route to a rating higher than 10% under any applicable VASRD §4.71a code for the left hip, knee, and shin pain condition.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating for the chronic hip, knee and shin pain condition as follows: an unfitting right and an unfitting left chronic hip, knee and shin pain condition, each rated 10%, both coded 5099-5022.  

BOARD FINDINGS:  In the matter of the chronic hip, knee, and shin pain condition, the panel recommends a disability rating as follows: an unfitting right and an unfitting left chronic hip, knee and shin pain condition, each rated 10%, both coded 5099-5022, IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Chronic Hip, Knee, And Shin Pain	5099-5022	10%	
Left Chronic Hip, Knee, And Shin Pain	5099-5022	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure