RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00628
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090106

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “bilateral hip, knee and pelvic pain” with a disability rating of 20%.

CI CONTENTION:  The CI made no specific contention.  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 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 progression or complications of service-connected conditions after separation.  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 - 20081211	VARD - 20150603	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hip, Knee and Pelvic Pain 
	5299-5255	20%	Left Hip Pain	5254	 NSC	STR	
			Right Hip Pain	5254			
			Right Knee Pain	5257			
			Left Knee Pain	5257			
			Pelvic Pain	5299-5294			
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Bilateral Pelvic, Hip, and Knee Pain.    The panel provides the following clarification regarding its approach to PEB consolidated ratings.  The PEB combined bilateral pelvic, hip, and knee pain under a single service disability rating as elaborated below.  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.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI experienced an atraumatic onset of bilateral pelvic, hip, and knee pain in July 2008 during Basic Training.  An initial bone scan demonstrated stress reactions at the knees (medial tibial plateaus) and stress fractures of the inferior pubic rami (IPR).  Of note, the IPR is adjacent to and helps support the hip socket, and there was no bone scan uptake at the hip joints.  Subsequent bone scans (at 7 and 5 months before separation) demonstrated resolution of the knee uptake and progressively healing IPR stress fractures; and, magnetic resonance imaging (MRI) of the pelvis (contemporaneous with the last bone scan) was interpreted as normal.  There were no STR entries that suggested any significant hip or knee range of motion (ROM) limitation or functional impairment, or that documented any additional VASRD-ratable findings.  

The 17 November 2008 NARSUM examination, 10 weeks prior to separation, documented “chronic bilateral hip pain, pelvic pain and bilateral knee pain” rated 3/10 and “exacerbated by prolonged standing, walking and any impact activities.”  The physical examination (all findings bilateral) recorded “mild” tenderness over the IPS, no tenderness over the hips, no joint line tenderness at the knees but some tenderness over the tibial plateaus, full lower extremity strength (5/5), and the absence of knee effusion, instability, or impingement.  

The NARSUM cited ROM measurements by physical therapy (PT) that were conducted on 8 October 2008 (5 weeks earlier).  Measured bilateral hip ROM was flexion to 95 degrees right and 100 degrees left (normal 125, 45 for minimum 10%); bilateral extension to 10 degrees (normal 20, 5 for maximum 10%); and, abduction to 20 degrees right and 23 degrees left (normal 45, 10 for minimum 10%).  Measured bilateral knee ROM was flexion to 122 degrees right and 130 degrees left (normal 140, 45 for minimum 10%), and bilateral extension to minus 0 degrees (normal).  Painful motion specified for each joint (hips and knees).

Of probative note, the NARSUM (by a physician extender) documented continued knee pain, even though the associated stress reactions had been resolved for at least several months by bone scan.  The physical medicine provider following the case, however, made clinical entries in the STR, one dated the same day as the PT ROM and another dated the same day as the NARSUM.  These documented that the CI continued to have hip pain, but each entry stated that the CI had “no primary complaint of pain in the knees at this time.”  Also of note, the PEB’s DA Form 199 decision referenced STR documentation of “right hip pain is greater than left and knee pain is intermittent,” although the source of that evidence could not be located in available records.

The MEB’s DA Form 3947 submission separately listed the hip, pelvic, and knee conditions as failing retention standards.  The permanent L3 profile was for “chronic bilateral hip, pelvic and bilateral knee pain.”  The commander’s performance statement did not provide evidence probative to separate fitness implications of different conditions.

The CI failed to report for a scheduled VA rating examination, but there were some VA outpatient clinical entries in evidence proximate to separation.  One referenced hip and knee pain and another referenced “pain to bilateral legs,” but neither documented ROM limitation or other ratable findings.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 20% rating for all conditions under the single code 5299-5255 (analogous to femur impairment rated for contiguous hip and knee pain) acknowledged VASRD §4.59 (painful motion) and VASRD §4.40 (functional loss); and, clarified that the rating was 10% for each extremity, specifying the applicable “slight” disability criterion under code 5255.  Code 5255 offers additional ratings of 20% for “moderate” and 30% for “severe” knee or hip disability.  The VA treated the conditions separately with application of codes 5254 (hip, flail joint), 5257 (knee instability), and 5299-5294 (analogous to pelvic fracture rated under criteria of the general spine formula); but, did not service-connect any of them.  Although citing the STR in evidence and noting the CI’s failure to report for a formal rating examination, the VA decision referenced the above VA treatment notes in its rationales.  It acknowledged the presence of pain which “in and of itself [is] not a disability;” but, asserted for each condition that no “disability has been clinically diagnosed.”

The de facto PEB adjudication was separate 10% ratings for each extremity, not a consolidated rating for potentially six bundled conditions (right and left IPR stress fractures, hip pain, and knee pain).  Members thus agreed that the core decision in this case was whether any of the individual conditions affecting each extremity should be unbundled for separate right and left ratings.  

With regards to the IPR stress fractures and hip pain, members agreed that it was overly speculative to separate distinct pathologies and disabilities for the IPR stress fractures and hip pain, since the latter was attributable to the former (more likely than not).  Members further agreed that, even if the existence of separate diagnoses and conditions were conceded, they could not be separately coded and rated without violation of VASRD §4.14 (avoidance of pyramiding).

With regards to the knee pain, members agreed that there was convincing evidence that the knee conditions could not be justified as separately unfitting at the time of separation (with application of the standard elaborated above).  There was objective bone scan evidence that the etiology (tibial plateau stress fractures) was resolved or near resolved by the time of separation; and, there was substantial STR evidence that the knee pain itself was no longer significant.  

It would be a moot exercise, however, to adjudicate the knees as not separately unfitting, since the unfitting hips (subsuming the IPR stress fractures) would still mandate separate ratings; and, assuming no rating higher than 10% for each joint was justified, the outcome would be equivalent to that already conferred by the PEB.  Members agreed that there was no ROM limitation or other ratable finding that would justify a rating higher than 10% for any of the affected joints in this case under any applicable code available in VASRD §4.71a; and, this included consideration for a higher rating under the above criteria of code 5255; with members agreeing that the functional limitations in evidence were more closely aligned with “slight” rather than “moderate” disability.  Given that the PEB’s analogous femur code for each lower extremity would accommodate rating for the hips (subsuming the IPR stress fractures) and the knee stress fractures (resolving or resolved at separation), members agreed that there was no satisfactory defense for making an alternate recommendation.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the bilateral pelvic, hip, and knee conditions.

BOARD FINDINGS:  In the matter of the bilateral pelvic, hip, and knee conditions and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

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

AR20170007489, XXXXXXXXXXXXXXXXXX. 

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,