RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01936
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041111

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Machinist, medically separated for “pain in lower extremities; hips, knees, ankles and legs,” 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 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 - 20040803	VARD - 20051025	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain in Lower Extremities, Hips, Knees, Ankles, Legs	5099-5003	20%	Left Hip Strain	5252	10%	20050124	
			Right Hip Strain	5252	10%		
			Right Knee and Leg Strain	5262-5257	10%		
			Left Knee and Leg Strain	5262-5257	10%		
			Right Ankle Strain	5271	10%		
			Left Ankle Strain	5271	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity (LE) Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI attributes his LE pain condition to slipping and falling while running in formation on snow in December 2000.  The first mention of lower extremity pain in the STR is left ankle pain noted 23 October 2000 without history of trauma.  The CI continued to have bilateral (right more than left) knee pain complaints that were diagnosed as patellar tendinitis and retropatellar pain syndrome.  The CI was referred for a bone scan on 17 December 2002 which showed stress related injury to the proximal right tibia, the anterior activity was thought to possibly be related to patellar tendon injury or tendinitis.  He continued to be treated with medications, physical therapy and steroid injections to the right knee with little to no improvement in symptoms.  Bilateral ankle and knee X-rays were normal.  There was no surgical indication and the bilateral knee pain condition could not be adequately rehabilitated to allow the CI to fulfill all of the activities of his MOS.  The MEB forwarded “chronic tibial stress fracture and retro patellar pain” for PEB adjudication in April 2003.  The initial PEB found the CI fit for duty.  The CI continued to complain of bilateral knee pain and by March of 2004 he also complained of right ankle pain.  On 07 April 2004, the CI underwent a second bone scan which showed mild, diffuse, asymmetric stress related changes throughout the left greater than right lower extremities without evidence of recent stress fracture and consistent with asymmetric weight bearing.  In addition, there was mild focal stress reaction in both tibial tuberosities as well as mild diffuse stress reactions throughout both hip joints.  On 01 June 2004 the CI stated he had been having bilateral hip pain for 7 months with no history of trauma.  He was referred for a rheumatology evaluation and on 15 June 2004 he described a 2-3 year history of bilateral ankle, shin, knee, hip and lumbosacral spine pain.  The rheumatologist concluded that the CI had longstanding overuse symptoms of the bilateral weight bearing lower extremities and that the symptoms appeared to be function limiting despite adequate treatment trials.  The second MEB forwarded “lower extremity pain in hips, knees, ankles, & legs with over use symptoms of bilateral weight bearing” for PEB adjudication.  

At the 4 June 2004  MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported foot trouble; impaired use of arms, legs, hands, or feet; swollen or painful joints; knee trouble, any need to use corrective devices…; and broken bones for the previous 3 years after slipping on a patch of ice.  He also reported trouble sleeping due to pain in knees, ankles, hips, and shins.  Physical examination showed pain on range of motion (ROM) measurements of the ankles, knees and hips.  The 15 June 2004 rheumatology evaluation, 5 months prior to separation, noted complaints of bilateral ankle, shin, knee, hip, and lumbosacral spine pain that was worse with walking and lifting and better with rest and medication.  Physical examination showed full ROM of all joints without synovitis, crepitus, or deformity (measurements listed in the chart below).  The examiner did note a normal gait and scattered tenderness at the left knee, right hip and above both ankles.  The 30 June 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of insidious onset of pain in his knees, ankles, and hips after the initial injury in December 2000 that was aggravated by running, walking, prolonged sitting or standing, wearing gear including flak vest, ruck sack, load bearing equipment and Kevlar helmet.  He reported that he was unable to run or walk further than 1 mile, stand for longer than 20 minutes or lift more than 20 pounds.  Physical examination referenced the MEB examination of 04 June 2004 and does not add additional ratable information.  

At the 24 January 2005 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported bilateral hip pain on a daily basis after standing for more than an hour, sitting for more than 2 hours or walking more than 1/2 mile.  The CI also complained of daily knee pain associated with standing more than an hour or walking over 1/2 mile.  In addition, he complained of his feet being numb and painful mostly during running or walking.  He denied laxity or giving out of the ankles.  Physical examination showed a normal gait.  ROM measurements are listed in the charts below.  The CI was sent for bilateral hip, knee, lower leg and ankle X-Rays on 24 January 2005 that were all read as normal.  

The range of motion (ROM) examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Right/Left Ankle ROM
(Degrees)	MEB ~5 Mos. Pre-Sep	VA C&P ~2 Mos. Post-Sep	
Dorsiflexion (20 Normal)	10,10,10/0,0,0	15/20	
Plantar Flexion (45)	(45) 50,50,50/45,45,45	45/45	
Painful motion	Bilaterally 	With dorsiflexion on R	
Abnormal gait	Not addressed	Absent	
Other impairments* 	Not addressed	TTP	

Right/Left Knee ROM
(Degrees)	MEB ~5 Mos. Pre-Sep	VA C&P ~2 Mos. Post-Sep	
Flexion (140 Normal)	125,125,125/120,120,120	117/110	
Extension (0 Normal)	0,0,0/0,0,0	0/0	
Comment	Painful motion bilaterally	Painful motion bilaterally. 	

Right/Left Hip (Thigh) ROM
(Degrees)	MEB ~5 Mos. Pre-Sep	VA C&P ~2 Mos. Post-Sep	
Flexion (125 Normal)	95,95,95/95,95,95	110/110	
Extension (20)	Not addressed	Not addressed	
External Rotation (45)	30,30,30/35,35,35	40/45	
Abduction (0-45)	40,40,40/40,40,40	40/45	
Adduction (45)	Not addressed	30/30	
Comment	Painful motion bilaterally	Painful motion on right	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled bilateral LE pain condition 20%, analogously coded 5099-5003 (degenerative arthritis), citing bone scan evidence of stress reactions.  The VA unbundled the bilateral LE pain conditions and rated each separately.  Each hip was 10% coded 5252 (thigh, limitation of flexion), 10% each for each knee and leg strain, analogously coded 5262-5257 (knee, other impairment) and 10% for right ankle strain coded 5271 (ankle, limitation of motion), citing variations in ROM and limited motion due to pain, fatigability and lack of endurance.  The VA rated the left ankle strain 0%, coded 5271, citing lack of painful motion, limitation of motion, or instability.  

As stated above, the PEB combined the right hip pain, left hip pain, right knee pain, left knee pain, right ankle pain and left ankle pain conditions as a single unfitting condition coded analogously coded 5099-5003 and rated 20%.  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 or implied adjudication that each condition was separately unfitting.  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.  

Right Hip Pain.  The panel noted complaints of hip pain but no X-Ray evidence of arthritis to justify rating using code 5003 though there was evidence of stress reaction on bone scan.  The panel agreed that there was insufficient limitation of range of motion to provide a minimum rating using VASRD codes 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of) or 5253 (thigh, impairment of).  In addition, there was no indication of a flail joint of the hip to support an 80% rating using code 5254, ankylosing of the hip to support a 60% rating using code 5254 or malunion of a femur fracture to support a 10% or higher rating using code 5255.  The panel did find that there was sufficient evidence of painful motion (VASRD §4.59) to support a minimum 10% rating analogously code 5299-5252.  

Left Hip Pain.  The panel similarly noted complaints of hip pain but no X-Ray evidence of arthritis to justify rating using code 5003 still there was evidence of stress reaction on bone scan.  The panel agreed that there was insufficient limitation of range of motion to provide a minimum rating using VASRD codes 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of) or 5253 (thigh, impairment of).  In addition, there was no indication of a flail joint of the hip to support an 80% rating using code 5254, ankylosing of the hip to support a 60% rating using code 5254 or malunion of a femur fracture to support a 10% or higher rating using code 5255.  The panel did find that there was sufficient evidence of painful motion (VASRD §4.59) to support a minimum 10% rating analogously coded 5299-5252.  

Right Knee Pain.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) analogously coded 5299-5260.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  After due deliberation, considering all of the evidence, the panel recommends a disability rating of 10% for the right knee pain condition, analogously coded 5299-5260.

Left Knee Pain.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) analogously coded 5299-5260.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  After due deliberation, considering all of the evidence, the panel recommends a disability rating of 10% for the left knee pain condition, analogously coded 5299-5260.  

Right Ankle Pain.  There was no limitation of dorsiflexion or plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271) or ankle, ankylosis of (5270).  There was also no ankylosis of the subtalar joint (5272), deformity or removal of the talus (5373, 5274).  However, there was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45) analogously coded 5299-5271.  

Left Ankle Pain.  There was no limitation of dorsiflexion or plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271) or ankle, ankylosis of (5270).  There was also no ankylosis of the subtalar joint (5272), deformity or removal of the talus (5373, 5274).  However, there was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45) analogously coded 5299-5271.  

BOARD FINDINGS:  In the matter of the right hip pain condition, the panel unanimously recommends a disability rating of 10%, analogously coded 5299-5252 IAW VASRD §4.71a.  In the matter of the left hip pain condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5252 IAW VASRD §4.71a.  In the matter of the right knee pain condition, the panel unanimously recommends a disability rating of 10%, analogously coded 5299-5260 IAW VASRD §4.71a.  In the matter of the left knee pain condition, the panel unanimously recommends a disability rating of 10%, analogously coded 5299-5260 IAW VASRD §4.71a.  In the matter of the right ankle pain condition, the panel unanimously recommends a disability rating of 10%, analogously coded 5299-5271 IAW VASRD §4.71a.  In the matter of the left ankle pain condition, the panel unanimously recommends a disability rating of 10%, analogously coded 5299-5271 IAW VASRD §4.71a.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Hip Pain	5299-5252	10%	
Left Hip Pain	5299-5252	10%	
Right Knee Pain	5299-5260	10%	
Left Knee Pain	5299-5260	10%	
Right Ankle Pain	5299-5271	10%	
Left Ankle Pain	5299-5271	10%	
COMBINED	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150507, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009306, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 50% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure