RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00534
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070720

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Basic Trainee, medically separated for “left knee tendonitis and right hip bursitis” and “mild stress fracture S-I joint,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI requests the panel consider all conditions.  The 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 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 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 determinations 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 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 - 20070628	VARD - 20150722	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Patellar Tendonitis and Right Hip Greater Trochanteric Bursitis 	5099-5003	10%	Left Knee Tendonitis	5260	10%	20150721	
			Symphysis Pubis Arthritis … Extension	5003-5251	10%		
			Symphysis Pubis Arthritis … Flexion	5003-5252	0%		
			Symphysis Pubis Arthritis …Thigh	5003-5253	0%		
Mild Stress Fracture Sacroiliac Joint with Back Pain	5022	0%	Lumbar Degenerative Disc Disease	5242	20%		
			Radiculopathy, Right Lower Extremity	8520	10%		
			Radiculopathy, Left Lower Extremity	8520	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Left Knee Tendonitis.  The PEB combined the left knee and right hip under a single service disability rating, coded 5099-5003 (analogous to degenerative arthritis) and rated 0%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and that 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 that it alone would not have caused 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 left knee and right hip conditions are therefore presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented the onset of left knee pain late in basic training without specific injury.  There were bone scan findings consistent with a possible stress fracture (medial tibial plateau), but the working diagnosis was patellar tendonitis.  There was documentation in STR clinical entries of normal range of motion (ROM) without annotation of painful motion and documentation of joint stability with no impingement (locking).  There were no contrary entries regarding any of these findings.  Surgery was not indicated, conservative treatment did not result in sufficient improvement to allow unrestricted duty, and the CI was referred for MEB which in turn forwarded “left knee pain secondary to patellar tendonitis” to the PEB.

The orthopedic NARSUM examination on 12 June 2007, 5 weeks before separation, documented constant pain and referenced only the inability to satisfy physical fitness standards and general soldiering requirements as functional limitations.  The physical examination recorded a “slight antalgic gait favoring the right knee,” patellar tenderness, no effusion, 4-plane stability to stress testing, and the absence of impingement.  Measured left knee ROM was flexion to 120 degrees (normal 140) and extension to minus 10 degrees (normal 0), with painful motion noted.  The left knee condition was not listed on the profile at separation, but was implicated in the commander’s statement, and it was separately forwarded by the MEB as failing retention standards.

There was no VA Compensation and Pension (C&P) examination until 21 July 2015, 8 years after separation, thus, it was marginally probative.  The examiner documented left knee flexion to 120 degrees, normal extension, painful motion, and no additional ratable findings.  The VA’s 10% rating under code 5260 (limitation of flexion) cited painful motion.  

The panel directed attention to its recommendation based on the above evidence and first considered whether the left knee condition, having been de-coupled from the combined PEB adjudication with the hip, was reasonably justified as separately unfitting.  In this case, there was no evidence that one joint caused more functional impairment than the other, and the overall functional impairment rendered the CI incapable of completing necessary training and continuing military service.  Although not profiled, the left knee condition was recognized by the commander as contributing to the CI’s unfitting impairment, and was separately judged to fail retention standards.  The limitations due only to the left knee could not extricated from the overall unfitting impairment, and it was unduly speculative to conclude that it would not have independently precluded further training and military service.  Members thus agreed that the left knee condition was reasonably justified as separately unfitting.  

Having agreed that the left knee was subject to separate rating, members turned to deliberation of the appropriate rating recommendation.  Painful motion was supported by the NARSUM evidence in justification of a 10% minimum rating (VASRD §4.59), as was the 10% criterion of code 5261 (limitation of extension).  There was no persistent effusion and locking, or fracture with non-union or malunion, to achieve a rating higher than 10% under any applicable code and there was no evidence for joint instability for separate rating.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends the left knee condition as separately unfitting with a 10% rating under code 5024 (tenosynovitis).

Right Hip Bursitis.  The CI developed right hip pain associated with the rigors of basic training concurrently with the left knee condition as above.  Normal findings were reported on X-ray; there was no hip joint uptake on bone scan and there were no further imaging studies in evidence.  There were STR entries that documented grossly normal ROM, with one that stipulated painful motion although there were two that recorded flexion to 100 degrees (normal 125).  There were no entries that indicated more significant ROM limitation or that documented any additional ratable findings.  Surgery was not indicated and conservative treatment did not result in sufficient improvement to allow unrestricted duty.  The CI was referred for an MEB which in turn forwarded “right hip pain, greater trochanteric bursitis” to the PEB.

The NARSUM documented constant pain and referenced only the inability to satisfy physical fitness standards and general soldiering requirements as functional limitations.  The physical examination recorded tenderness over the greater trochanter with no other positive findings.  Measured ROM was flexion to 112 degrees, extension to 20 degrees (normal), external rotation to 45 degrees (normal), abduction to 41 degrees (normal 45), and adduction to 30 degrees (normal 45) with painful motion noted.  The hip condition was not listed on the profile at separation, but was implicated in the commander’s statement and it was separately forwarded by the MEB as failing retention standards.

The same temporally remote VA C&P examination documented minor and non-compensable ROM limitations with painful motion and the VA’s 10% rating under code 5003-5251 (limitation of extension) cited painful motion.

The panel directed attention to its recommendation based on the above evidence and as with the left knee, first addressed the question of whether it was reasonably justified as separately unfitting.  The panel initially considered whether a bilateral combined rating under criteria of 5003 (as per the PEB) could be supported by a conclusion that the knee and hip were only unfitting by virtue of combined effect.  Members agreed however, that it was not sufficiently clear that this was the case.  Furthermore, the PEB stated the position that the “with X-ray evidence” criterion of 5003 was not essential in the case of a soft-tissue diagnosis.  That is not a prerogative under VASRD §4.71a.  However, all imaging findings for the hip were normal.  Given the absence of a VASRD-compliant pathway to a combined rating in this case, and an inability to reasonably justify either joint as not separately unfitting, the panel concluded that it could not adequately defend a recommendation for a single rating of both joints.  The fitness evidence for the right hip was equivalent to that for the left knee and under the same rationale, the panel’s conclusion was the same.  There was not a preponderance of evidence that the limitations due solely to the right hip would have permitted continued training and military service.  Members thus agreed that the condition was reasonably justified as separately unfitting.  

Having agreed that the right hip was subject to separate rating, members turned to deliberation of the appropriate rating recommendation.  There was no ROM limitation, ankylosis, flail joint, or instability that would satisfy a ratable criterion of any §4.71a code, but there was ample documentation of painful motion in support of the minimum 10% rating.  After due deliberation, considering all of the evidence and with deference to reasonable doubt, the panel recommends the right hip condition as separately unfitting with a 10% rating under code 5019 (bursitis).

Mild Stress Fracture Right Sacroiliac Joint (SIJ).  Concurrently with the atraumatic onset of right hip pain, the CI complained of right groin, and later, right lower back (sacroiliac) pain.  A bone scan demonstrated uptake in the right SIJ consistent with a “small” stress fracture.  There was no lower extremity radiation or radicular symptoms (specifically denied in several entries).  Multiple normal neurological examinations were in evidence, with none to the contrary.  There were two physical therapy entries (a week apart, same examiner) that recorded thoracolumbar flexion to 65 degrees (normal 90) with painful motion, but grossly normal ROM in other planes; and, there was no other thoracolumbar ROM evidence in STR clinical entries.  A normal gait was documented in some entries, and there were no entries that linked gait disturbance with the spine or noted an abnormal spinal contour, and there was no STR documentation of incapacitating episodes.  Surgery was not indicated and conservative treatment did not result in sufficient improvement to allow unrestricted duty.  The CI was referred for an MEB which in turn forwarded “right [SIJ] stress fracture” to the PEB.

The NARSUM documented nonspecific back pain “90% of the time” and referenced only the inability to satisfy physical fitness standards and general soldiering requirements as functional limitations.  Radicular symptoms were denied.  The physical examination recorded tenderness over the right SIJ and lower “L3 through S1” lumbosacral region, normal neurological findings, and 5/5 strength.  Measured thoracolumbar ROM was normal in all planes (flexion to 90 degrees and combined ROM of 240 degrees), without comment regarding painful motion.

The temporally remote VA C&P examination documented continued pain, with bilateral lower extremity radiation and paresthesias.  The physical findings included flexion to 60 degrees (combined 120) and normal neurological findings.  The VA’s 20% rating under code 5242 (degenerative arthritis of the spine) cited the flexion criterion, and separate radiculopathy ratings were conferred for the radicular complaints that were not present at separation.

The panel directed attention to its rating recommendation based on the above evidence.   The PEB’s 0% rating was under code 5022 (periostitis) that defaults to criteria of 5003, not to criteria of the §4.71a general spine formula and cited “ROM limited by pain.”  Given the NARSUM evidence of normal thoracolumbar ROM without documentation of painful motion, the panel was uncertain of the origin of the evidence cited by the PEB and a concession of painful motion would rely on provisions of Army Regulation 635-40 (B-29, e) to supersede VASRD §4.59 in support of a minimum compensable rating.  The panel noted that the pathology and disability lent itself to rating under the spine code 5236 (sacroiliac injury and weakness), applying criteria of the spine formula in lieu of 5003 criteria.  With regards to spine rating, the only ROM evidence that was temporally probative to separation and compliant with VASRD §4.46 (accurate measurement) was that from the NARSUM.  The NARSUM evidence would require concession of painful motion, or rely solely on the isolated finding of tenderness to support the minimum 10% rating.  There was no evidence for abnormal gait or spinal contour to support a 20% rating, no evidence for ratable peripheral nerve impairment that would provide for additional rating, and no documentation of incapacitating episodes or service diagnosis of intervertebral disc syndrome that would provide for a higher rating under that formula.  

Members deliberated whether a recommendation for a 10% rating for the SIJ condition under code 5236, with concession of painful motion and/or tenderness, was justified.  Members considered, however, that any painful motion or tenderness of the SIJ greatly overlapped with that from the contiguous right hip and therefore the issue of pyramiding (VASRD §4.14) was a significant consideration in this case.  It was clinically logical, in fact, that the primary culprit for the hip pain (and consequent ROM limitation) was the SIJ stress fracture identified as the sole pathology on the bone scan.  If that were to be assumed, however, then the criteria necessary to satisfy a minimum 10% hip rating as above would have had to rely heavily if not exclusively, on the pain and disability attendant to the SIJ condition.  The converse also would logically be true as the findings and disability necessary to support a minimum 10% rating for the SIJ condition, whether under criteria of 5022 or 5236, were equivalent to those already captured in the hip rating.  Members thus agreed that concession of painful motion and/or tenderness in support of a minimum 10% rating for the SIJ condition would constitute, at least to an unacceptable degree, a violation of VASRD §4.14.   
After due deliberation, considering all of the evidence and with deference to reasonable doubt, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the right SIJ condition.

BOARD FINDINGS:  In the matter of the PEB-combined left knee and right hip conditions, the panel unanimously recommends that it be rated for separately unfitting conditions as follows:  the left knee coded 5024 with a disability rating of 10% and the right hip coded 5019 with a disability rating of 10%, both IAW VASRD §4.71a.  In the matter of the right sacroiliac stress fracture and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication. 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	
Patellar Tendonitis, Left Knee	5024	10%	
Greater Trochanteric Bursitis, Right Hip	5019	10%	
Right Sacroiliac Stress Fracture	5022-5236	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150530, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006456, XXXXXXXXXXXXXXXXXX.

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Dear XXXXXXXXXXXXXXXXXX:

	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,