RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01998
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O3, Transportation Officer, medically separated for “chronic bilateral knee pain,” “chronic low back pain” and “chronic bilateral hip pain”,  rated 10%, 10% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI submitted a detailed contention prepared by counsel.  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 - 20070228	VARD - 20070604	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain…	5099-5003	10%	PFS, Right Knee	5099-5020	10%	20070315	
			PFS, Left Knee	5099-5020	10%	20070315	
Chronic Low Back Pain…	5237	10%	Lumbar Sprain	5237	10%	20070315	
Chronic Bilateral Hip Pain…	5099-5003	0%	Right Hip Sprain	5099-5020	10%	20070315	
			Left Hip Sprain	5299-5020	10%	20070315	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the bilateral knee pain condition as a single unfitting condition coded 5099-5003 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 also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 bilateral knee conditions is presented together, but 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 bilateral knee pain began in February 2004 following a road march.  The first record in evidence is a primary care note dated 7 July 2005 in which he reported left knee pain.  He was next seen on 14 October 2005 when he reported a 6 month history of bilateral knee pain without antecedent trauma.  He was treated with medications, duty limitations, and stretching.  X-rays of each knee on 25 April 2006 were normal.  Bilateral MRIs on 12 July 2006 showed a lateral meniscus tear (LMTs), the outside cartilage cushion, for the right knee.  No specific comment on the left knee was documented.  The CI was evaluated in orthopedics on 17 August 2006.  The commander noted (on 14 November 2006), as did the MEB NARSUM, that the CI was found to have bilateral tears of the lateral menisci.  His symptoms were attributed to patello-femoral syndrome (PFS) and surgery was not recommended.  A profile issued by the orthopedist that same day was for bilateral PFS and silent for a meniscal injury.  An examination in physical therapy on 18 October 2006 noted full and painless motion of the knees, but reduced strength in the left greater than right leg.  Tenderness was evident on palpation, but not noted with walking.  Instability was absent.  Testing for meniscal injury was positive bilaterally, but the examiner did not specify which meniscus was involved.  The CI was seen in orthopedics on 27 October 2006 and reported locking bilaterally.  He was noted to have a normal stance and gait.  The knees were stable and motion normal (implying full and pain free).  Tenderness was present over the right knee, but not the left.  Strength was normal for both legs.  The profile was updated to note bilateral knee pain secondary to meniscal tears.  No effusion was present.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated December 2006, 5 months prior to separation, the CI reported bilateral knee pain and the use of a brace.  The examination was checked “normal.”  The CI had range of motion (ROM) testing in physical therapy on 16 January 2007 as charted below.  Tenderness and guarding were present.  The gait was normal.  Motion was limited by pain.  The MEB NARSUM examination on 28 January 2007, 4 months prior to separation, noted complaints of that the CI had declined further evaluation or treatment of his knees.  This was thought to be reasonable.  It was noted that he was restricted from military activities including physical training.  Examination of both knees revealed full ROM.  Joint line tenderness was present, but the knees were otherwise unremarkable and without deformity, instability, pain with kneecap compression, or indications of plica.  It was noted that the MRI showed a bilateral tear of the lateral meniscus.  The language mirrored that of the actual report for the right knee.  The MRI report was silent as to findings for the left knee.  It is not clear if this is an error or if a bilateral tear was present.  

At the VA Compensation and Pension (C&P) evaluation performed on 15 March 2007, 2 months before separation, the CI reported bilateral knee pain since March 2004, easy fatigability, and locking.  He reported incapacitation at night, but this was not quantified.  His posture and gait were normal.  No assistive device was used.  The ROM was limited, but painful motion was not documented.  Instability was not present.  There was no further limitation with repetition.  X-rays of each knee were normal.  The 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.  

Knee ROM
(Degrees)	PT ~4 Mo. Pre-Sep	MEB ~4 Mo. Pre-Sep	VA C&P ~2 Mo. Pre-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	90,90,91	111,110,106	Full active range of motion	125	130	
Extension (0 Normal)	0,0,0	0,0,0		0	0	
Comment	Tenderness and guarding.  No abnormal gait	Painful motion not recorded	Nml gait.  Pain free motion.  Stable knees.	
§4.71a Rating	10%	10%	0%	0%	0%	0%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded analogously as 5003 (degenerative arthritis), citing full ROM and joint line tenderness.  The VA rated the bilateral knee condition 10% for each knee coded analogously as 5020 (synovitis), based on the C&P examination 2 months before separation, citing limitation of flexion and painful or limited motion, respectively.  The panel evaluated the evidence and first considered if the knees were separately unfitting.  Both were profiled, both were noted to be medically unacceptable by the MEB, and both were cited by the commander as impairing duty performance.  The evidence supported a finding that each knee was separately unfitting at separation.  

The panel then considered the rating.  Motion was limited on some examinations, but not to a level compensable under either code 5260 (limitation in flexion) or 5261 (limitation in extension).  The menisci were noted to be torn in the NARSUM (as discussed above).  Locking was reported, but not found on examination.  An effusion was not recorded.  Neither the code 5258 (dislocated meniscus) nor 5259 (removed meniscus) was supported by the evidence.  Instability was not present to support the use of the code 5257 (subluxation or lateral instability).  The panel then considered the codes 5003 and 5020.  Limitation in motion in the presence of an abnormal MRI supports a 10% rating for each knee if confirmed by swelling, spasm, or painful motion.  These were not present on either the C&P examination nor on the MEB examination.  A route to a rating higher than the 10% assigned by the PEB for both knees was not found.  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 for the bilateral knee condition.  

Low Back Pain.  According to STRs and the MEB NARSUM, the CI’s LBP began in April 2005 after while climbing in and out of vehicles.  The first record in evidence is an X-ray report dated 25 April 2006.  The CI reported LBP since his deployment.  On X-rays, abnormal spinal curvature was noted.  The CI was evaluated in primary care on 19 July 2006.  He was noted to have a normal gait and to move all extremities well.  He was treated in the chiropractic clinic on 28 July 2006 and noted to have full, but painful motion of the lumbosacral (not thoracolumbar) spine.  In orthopedics on 27 October 2006, the lumbosacral motion was normal (full and pain free).  Tenderness and spasm were absent.  

ROM testing in physical therapy was accomplished on 16 January 2007.  Markedly limited motion was present due to pain with flexion limited to 25 degrees (after rounding) and a combined ROM of 110 degrees (normal values are 90 and 240 degrees, respectively).  Spasm was not documented.  The MEB examination noted a normal spine.  The MEB NARSUM examination documented a normal gait and spinal curvature (although X-rays were abnormal as discussed above).  Tenderness was present without spasm.  The motor function and reflexes were normal.  It was noted that an MRI of the lumbar spine dated 8 November 2006, not otherwise in evidence, showed degenerative disc disease (DDD) at L4-5 without neurological compromise.  At the 15 March 2007 C&P evaluation, the CI reported weakness and constant pain which radiated down the left side of his body.  He reported incapacitation at night.  This was not quantified.  Physician prescribed bedrest was not documented (in the encounter or the remainder to the records in evidence).  On examination, the gait and posture were normal.  No assistive device was in use.  Motion was limited to 75 degrees flexion and 210 degrees combined ROM.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the LBP 10%, coded 5237 (lumbosacral strain), citing limited motion.  The MEB values obtained in physical therapy support a 40% rating.  However, these values are an outlier from the remainder of the record with values prior to this typically normal and the VA values were near normal.  The MEB values are inconsistent with the level of disease seen on the MRI report and with the normal gait which was typically recorded.  This examination has reduced probative value and is not used for rating purposes.  The C&P was the most proximate to separation, employed a goniometer, and is consistent with the MRI and remainder of the record.  It is assigned a higher probative value and is used for rating purposes.  It supports a 10% rating for limitation in motion.  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 for the LBP condition.  

Chronic Bilateral Hip Pain.  The PEB also combined the bilateral hip pain condition as a single unfitting condition coded 5099-5003 and rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy.  As discussed above for the bilateral knee condition, the evidence for the bilateral knee conditions is presented together, but with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to STRs and the MEB NARSUM, the CI’s bilateral hip condition began in April 2005 while climbing in and out of vehicles.  The first record in evidence is an X-ray report dated 7 August 2006 which noted that the pelvis was normal.  The CI was seen in physical therapy on 14 August 2006 for snapping hip syndrome.  He reported a popping noise when getting up from a chair and with walking any distance.  On examination, the ROM was normal.  Motor function was slightly reduced bilaterally at 4+/5.  Bursae (fluid filled sacs to reduce friction) were tender bilaterally.  Instability was absent.  A vaulting gait (rising up on the toes during walking) was present, right greater than left.  He was treated in physical therapy over the next few months.  In orthopedics on 27 October 2006, the motion was normal and pain free.  Tenderness was no longer present.  His strength was normal as was the gait.  The ROM was measured in physical therapy on 16 January 2007 and is charted below.  It was noted that he could cross his legs.  Motion was limited by pain.  Flexion was limited to 60 degrees on the left and 70 degrees on the right on formal testing.  However, the examiner noted that the CI demonstrated greater than 90 degrees of flexion bilaterally when sitting and when transitioning to standing.  The CI demonstrated guarding and resisting when the passive ROM measurements were taken.  The probative value of this examination is accordingly reduced.  The MEB examination was normal.  The MEB NARSUM examination noted complaints of frequent popping of both hips.  On examination, the gait was normal.  No specific areas of tenderness were present.  Motion was not painful.  X-rays were noted to be normal.  

At the C&P evaluation, the CI reported stiffness, dislocation, and giving way.  He functioned with pain, but without medications.  He denied incapacitation.  On examination, the gait and posture were normal.  The general appearance of the hips was normal.  The ROM was reduced as charted below, but painful motion was not recorded.  No additional limitations were noted with repetition.  X-rays were normal.  

The 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.  

Left/Right Hip (Thigh) ROM
(Degrees)	PT ~4 Mo. Pre-Sep	VA C&P ~2 Mo. Pre-Sep	
	Left	Right	Left	Right	
Flexion (125 Normal)	60,58,60	74,72,70	105	100	
Extension (20)	10,10,10	11,10,9	30	30	
External Rotation (45)	19,19,19	18,18,20	40	45 (50)	
Abduction (45)	20,17,18	18,18,22	40	40	
Adduction (45)	17,18,18	10,10,12	25	25	
Comment	Pain/tenderness.  Flexion was over 90 degrees when sitting	Painful motion not recorded	
§4.71a Rating	0%	0%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral hip pain 0% for the bilateral hip condition, coded analogously as 5003 (degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy.  The VA rated each hip at 10%, analogously coded 5299-5020 (synovitis), based on the C&P examination 2 months before separation, citing limitation of forward flexion.  The panel first considered if the hips were separately unfitting.  Both were found to be medically unacceptable, bilateral hip pain was profiled, and the commander cited (bilateral) trochanteric (part of the hip) bursitis.  The evidence supports a finding that each was separately unfitting.  

The panel then considered the rating.  The limitation in motion was not compensable under the codes 5251 (limitation in extension), 5252 (limitation in flexion), and 5253 (other impairment of the thigh).  The panel then considered the use of the codes 5003 and 5020.  X-rays were noted to be normal on both the MEB and VA examinations.  Swelling, muscle spasm, and painful motion were not recorded.  The panel found no route to a compensable rating for the hip condition, either separately or as a single condition.  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 for the bilateral hip pain condition.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral hip condition 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, 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 20150720, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010706, XXXXXXXXXXXXXXXXXX 

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.

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX
Sincerely,