RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02092
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040420

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Water Treatment Specialist, medically separated for “chronic hip and shoulder pain” with a disability rating of 10%.

CI CONTENTION:  The CI indicates that her disability evaluation system process was rushed; and that she continues to suffer from flat feet, five herniated disks and a pinched nerve in her back (which caused left hip pain), cervical strain and headaches, left knee strain, hypothyroidism and depression.  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 - 20040120	VARD - 20040901	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Hip & Shoulder Pain	5099-5003	10%	Bilateral Hip Pain	5099-5024	NSC	20040617	
			No VA Placement of Shoulder	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Hip and Shoulder Pain.  The PEB combined two conditions forwarded by the Medical Evaluation Board (MEB) of bilateral hip pain and right shoulder pain as a single unfitting condition “chronic hip and shoulder pain” coded analogously to 5003 (degenerative arthritis) and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  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 chronic hip and chronic shoulder pain conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Chronic Hip Pain.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI’s chronic hip pain condition began in approximately April 2000 after running.  Initially the CI reported left hip pain, but later bilateral hip pain.  The NARSUM noted multiple visits throughout 2000 for treatment of left hip pain.  In February 2002 left hip pain was again noted and a permanent L2 was initiated for left hip pain.  An MRI of the bilateral hips in September 2002 was unremarkable.  Notes in the STR indicated that MEB was dictated in November 2002.  The commander’s statement dated 17 October 2002 implicated the CI’s chronic pain of both hips as impairing the CI’s duty performance.  The permanent profile dated 15 January 2004 listed chronic bilateral hip pain.  

During the 4 November 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 18 months prior to separation, the CI reported chronic left hip pain.  Physical examination showed “good” left hip range of motion (ROM).  There was no swelling or tenderness to palpation.  A bone scan to evaluate the left hip and orthopedic consult were recommended. 

An orthopedic evaluation on 26 February 2003, 14 months before separation, noted bilateral hip and anterior groin pain since 2000.  There was tenderness to palpation over the greater trochanter of the hip bilaterally and right greater than left anterior groin pain.  There was full ROM in all planes of the hips and pain with flexion was noted.  A bone scan showed mild symphysis pubis arthritis and normal hips.  

The 17 November 2003 MEB NARSUM examination, 5 months prior to separation, noted complaints of bilateral hip pain.  Physical examination showed right hip ROM of flexion to 85 degrees (normal 125) and abduction to 35 degrees (normal 45 degrees).  Left hip ROM was flexion of 80 degrees and abduction of 40 degrees.  There was good lower extremity strength and the CI was able to heel and toe walk.  The examiner noted bilateral hip X-rays on 26 February 2003 that were normal.  The MEB NARSUM examiner indicated the CI needed to continue her U3L3 profile and failed retention standards for bilateral hip and right shoulder pain.  

At the 17 June 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported bilateral hip pain.  She reported she could stand an hour and walk for a mile and did so on most days.  Physical examination showed a normal gait.  Hip ROM was equal bilaterally with 120 degrees flexion and 45 degrees of abduction, 25 degrees of adduction (normal 45), without painful motion.  There was no tenderness of the lower abdomen.  Back examination was normal.  Neurological examination was normal.  Bilateral hip X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic hip and shoulder pain condition 10%, coded 5099-5003 (degenerative arthritis), citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The VA did not service connect the bilateral hip condition based on the C&P examination 2 months after separation, citing no permanent residual or chronic disability was demonstrated by the evidence.  
The panel first considered if the bilateral hip condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The commander’s statement implicated both hips and the permanent profile listed bilateral hip pain.  The MEB NARSUM indicated the CI fell below retentions standards due to bilateral hip pain.  The panel concluded that there was not a preponderance of evidence of the service records that overcame the panel’s presumption that the bilateral hip condition was reasonably considered separately unfitting.  The panel next considered if both the right and left hips were separately unfitting.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either hip over the other.  Since undue speculation would be required to conclude that impairment from either hip would not have unacceptably interfered with MOS performance, members agreed that each hip was reasonably justified as separately unfitting.  

Since the relevant clinical evidence for rating the hips is essentially the same, the panel then considered its rating recommendation for the unfitting hip conditions together at the time of separation.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of thigh flexion or extension, or thigh impairment (5252, 5251, or 5253).  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) at either the MEB NARSUM or VA examinations.  Although there was evidence of arthritis of the pubic symphysis, there was no abnormal imaging of the hip joints to consider a bilateral 10% rating under 5003 for two or more major joints with imaging evidence of arthritis.  The examinations proximate to separation did not demonstrate the presence of hip ankyloses, flail hip joint, of femur impairment (5250,5254, 5255) for a rating under the respective codes.  There was therefore no route to a higher rating than 0% for either hip under any applicable VASRD §4.71a code.  

Chronic Shoulder Pain.  According to the STR and the MEB NARSUM, the CI’s dominant right shoulder condition began in September 2001 after push-ups.  A MEB was initiated for the hips in November 2002 but not completed due to a delay in the completion of evaluation of the right shoulder.  The commander’s statement implicated the CI’s shoulder problems as impairing the successful performance of her duties.  The permanent profile dated 15 January 2004 listed right shoulder pain.  

During the 4 November 2002 MEB examination the CI reported that her shoulder dislocated during physical training and several times after that.  The physical examination showed “good” ROM of the shoulder.  There was no swelling or instability.  There was anterior tenderness to palpation.  There was no sign of impingement with examination maneuvers.  Right shoulder X-rays were recommended.  

Right shoulder and bilateral acromioclavicular (AC) X-rays in October 2003 were normal.  At an orthopedic evaluation of the right shoulder on 4 November 2003, 6 months before separation, the CI reported sporadic right shoulder pain and numbness with normal routine daily activities.  She reported the symptoms began while doing push-ups when she felt a pop and subluxation in her shoulder.  The physical examination showed full ROM with pain with full overhead abduction.  There was mild decrease (in ROM) of abduction and internal rotation with repetitive ROM (graded 4/5).  There was no tenderness to palpation.  There was no evidence of impingement, biceps tendon injury, dislocation or relocation of the shoulder with examination maneuvers.  The orthopedic assessment was shoulder pain after subluxation a year ago.  Physical therapy (PT) was recommended and a temporary profile for push-ups was provided, but the CI had already been assigned a U3L3 profile earlier in October 2003.  A note dated 16 December 2003 indicated the CI had been unable to start PT and a new consult was ordered.  

The 17 November 2003 MEB NARSUM examination, 5 months prior to separation, noted complaints of right shoulder pain.  Physical examination showed right shoulder flexion of 140 degrees and abduction of 115 degrees.  There was no pain with full overhead abduction noted.  There was good upper extremity strength, but wincing was noted with testing.  There was no AC joint tenderness.  The MEB NARSUM examiner indicated the CI needed to continue her U3L3 profile and failed retention standards for bilateral hip and right shoulder pain.  

At the 17 June 2004 C&P evaluation the CI reported recurrent right shoulder pain with overhead use and internal rotation.  Physical examination showed no tenderness or deformity of the AC joint.  There was 180 degrees of flexion and abduction (normal 180 for each), with painful motion noted.  Neurological examination was normal.  Right shoulder X-rays were unremarkable.  

The PEB rated the chronic hip and shoulder pain condition 10% as indicated above, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The original VA Rating Decision did not address the right shoulder.  

The panel first considered if the right shoulder condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The commander’s statement implicated shoulder problems and the permanent profile listed right shoulder pain.  The MEB NARSUM indicated the CI fell below retentions standards due to right shoulder pain.  The panel concluded that there was not a preponderance of evidence of the service records that overcame the panel’s presumption that the right shoulder condition was reasonably considered separately unfitting.  

The panel directed attention to its rating recommendation based on the above evidence.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) coded analogously to 5003.  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  There was therefore no route to a higher rating than 10% for the right shoulder condition under any applicable VASRD §4.71a code.  

After its deliberations, having unbundled the bilateral hip and shoulder conditions, the panel found that it did not result in a higher combined rating than the PEB’s initial adjudication.  The panel also noted that the PEB’s reliance on the USAPDA pain policy was not detrimental to arriving at the highest combined rating in this case.  Therefore, no change to the PEB’s combined adjudication is recommended.  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 chronic hip and shoulder conditions.  

BOARD FINDINGS:  In the matter of the chronic hip and shoulder pain 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 20150729, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170010710, XXXXXXXXXXXXXXXXXX 

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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,