RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00604
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20060430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Ground Mobile Forces Satellite Communications Operator, medically separated for “chronic left hip and knee pain” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  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 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 - 20060209	VARD - 20060811	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Hip and Knee Pain	5099-5003	0%	Patella Femoral Syndrome, Left Knee	5014-5260	0%	20060811	
			Left Hip Condition	5252	NSC		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  
 
Chronic Left Hip Pain.  The PEB combined the left hip and left knee conditions 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 makes separate fitness recommendations in this circumstance, the resulting combined rating may not be lower than that of the PEB.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) the CI experienced an onset of left hip pain with the rigors of basic training in 2005, without specific injury.  A bone and radiographic (X-ray) scan were normal.  The pain persisted and was diagnosed as fascial strain (iliotibial band syndrome).  There was documentation in STR clinical entries of normal range of motion (ROM), although there were two entries that specified painful motion.  There was no entry that indicated any significant ROM limitation or identified any other ratable finding.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow unrestricted duty.  

The 17 October 2005 NARSUM examination, 6 months before separation, documented “constant” pain rated 5-7/10 that prohibited running and was aggravated by prolonged walking or standing.  The physical examination recorded a normal gait, no hip tenderness, and no signs of joint impingement.  The NARSUM referenced formal ROM measurements performed on the same date for the MEB by physical therapy (PT).  Measured in degrees these were flexion to 95 (normal 125), extension to 8 (normal 20), external rotation to 45 (normal), abduction to 35 (normal 45), and adduction to 30 (normal 45). Both the PT and NARSUM examiners specified painful motion.

The commander’s non-medical assessment (NMA) did not specify any medical diagnoses and was not probative to separate fitness implications of the knee or hip.  An Army L3 profile was issued that listed left hip and knee pain, but did not identify any limitations that were not applicable to both joints.  

A 27 June 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, documented non-specific hip pain “with walking or sitting too long.  Standing does not appear to be a problem.”  The physical examination recorded a normal gait and did not document any positive (or negative) findings for the hip.  Measured ROM was normal in all planes, and there was no comment with regard to painful motion or DeLuca assessment.  Under diagnoses, the examiner listed, “no evidence to support a left hip condition based on symptoms and physical findings.”  

The panel directed attention to its recommendation based on the above evidence; and, first considered whether the hip condition, having been de-coupled from the combined PEB adjudication with the knee, 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 continued service.  It was specified, although not specifically differentiated, in the Army profile; and, was logically implicated (along with the knee) in the commander’s NMA.   The limitations due only to the left hip could not be extricated from the overall unfitting impairment, and it was unduly speculative to conclude that it would not have independently resulted in MEB referral and medical separation.  Therefore, member consensus was that the left hip condition was reasonably justified as separately unfitting.  

Having agreed that the condition was subject to separate service rating, members turned to deliberation of the appropriate rating recommendation.  There was no ROM limitation, ankylosis, flail joint, or instability to support the ratable criterion of any applicable code; but, there was explicit documentation of painful motion in support of the minimum 10% rating IAW VASRD §4.59.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel’s consensus recommendation was a 10% rating for the left hip under code 5024 (tenosynovitis) as a separately unfitting condition.

Chronic Left Knee Pain.  The CI developed atraumatic left knee pain concurrently with the hip pain during basic training.  X-ray and bone scan were normal; and, there were no relevant findings by magnetic resonance imaging (intact menisci and ligaments).  The pain persisted and was diagnosed as fascial strain (same etiology as hip).  Several STR entries documented grossly normal ROM.  There were some serial PT entries that provided measured ROM, all of which documented flexion to 125 degrees (normal 140) and extension to 0 degrees (normal); although, the examiner characterized these values as normal.  There were no entries that indicated more significant ROM limitation, and none that specified painful motion.  There was ample STR documentation of the absence of effusion, stability to stress testing, and negative signs of impingement; and, there were no entries to the contrary.  Surgery was not indicated and conservative treatment did not result in sufficient improvement to allow unrestricted duty.  

The NARSUM did not distinguish between joints with regard to the severity and the functional limitations described above for the hip.  The physical examination recorded “mild” knee tenderness and “negative meniscal and ligamentous signs.”   Formal ROM measurements by PT were flexion to 115 degrees and extension to 0 degrees.  Both the PT and NARSUM examiners specified painful motion.  Recall the preceding evidence with regard to fitness implications from the commander’s NMA and Army profile. 

The 27 June 2006 VA C&P examination documented non-specific left knee pain that was provoked by prolonged sitting, standing, and walking.  The physical examination recorded “minimal” tenderness, no effusion, 4-plane stability to stress testing, and no signs of impingement.  Measured ROM was normal in all planes, and there was no comment with regard to painful motion or DeLuca assessment.  The VA’s 0% rating under code 5252 (limitation of flexion), based on this examination, cited failure to meet 10% criteria.

The panel directed attention to its recommendation based on the above evidence; and, as with the hip, first addressed the question of whether the knee 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.  The consensus conclusion, however, was that it was not sufficiently clear that this was the case.  Furthermore, the “with X-ray evidence” criterion for rating under 5003, a VASRD §4.71a requirement, was not satisfied in this case because all imaging findings were normal.  Given the absence of a VASRD-compliant pathway to a combined rating, and an inability to reasonably justify either joint as not separately unfitting, panel consensus was that a recommendation for a single rating of both joints could not be adequately defended.  

The fitness evidence for the left knee was equivalent to that for the left hip; and, under the same rationales, the panel’s conclusion was the same.  There was not a preponderance of evidence that the limitations due solely to the left knee would have permitted continued military service.  Therefore, member consensus was that the condition was reasonably justified as separately unfitting.  

Having so concluded, members turned to deliberation of the appropriate rating recommendation for the knee.  There was no ROM limitation, persistent effusion and locking, or fracture with non-union or malunion to support a ratable criterion of any applicable code; and, there was no evidence for (or PEB stipulation of) joint instability for separate rating.  There was, however, explicit documentation of painful motion in support of the minimum 10% rating IAW VASRD §4.59. 

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel’s consensus recommendation was a 10% rating for the left knee under code 5024 as a separately unfitting condition.

BOARD FINDINGS:  In the matter of the PEB-combined left hip and left knee conditions, the panel majority recommends that they be rated for separately unfitting conditions as follows:  the left hip coded 5024 with a disability rating of 10% and the left knee coded 5024 with a disability rating of 10%, both IAW VASRD §4.71a.  The single voter for dissent recommends a modification to an overall 10% rating for both joints, and elected not to submit a minority opinion. There are 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 his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Fascial Strain, Left Hip	5024	10%	
Fascial Strain, Left Knee	5024	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 31 Jan 17 ICO XXXXXXXXXXXXXXXXXX      
	(c) PDBR ltr dtd 31 Mar 17 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 30 Jan 17 ICO XXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 04 Apr 17 ICO XXXXXXXXXXXXXXXXXX 
	(f) PDBR ltr dtd 31 Jan 17 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 30 Jan 17 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 27 Feb 17 ICO XXXXXXXXXXXXXXXXXX
      	(i) PDBR ltr dtd 17 Jan 17 ICO XXXXXXXXXXXXXXXXXX 

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.  The official records of the following individuals are to be corrected to reflect the stated disposition below:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     h. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.   
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)