RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02393
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060429

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Signal Support Systems Specialist, medically separated for “chronic pain, left hip and right knee,” with a disability rating of 10%.

CI CONTENTION:  The CI requests review all conditions.  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 - 20060321	VARD -  NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Hip and Right Knee	5099-5003	10%	No VA examination in evidence.  
	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Pain Left Hip.  The PEB combined the left hip and right knee pain conditions as a single unfitting condition coded analogously to 5003 and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  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 left hip and right knee pain conditions are presented separately, 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 left hip condition began in September 2005 while in basic training.  Motion was full but painful at the extremes for both hips.  Tenderness was also present bilaterally.  X-rays were normal.  He was treated with medications, crutches, and duty limitations.  He was also referred for a bone scan which was accomplished 2 weeks later and showed increased uptake over the left sacroiliac joint (SIJ, the joint between the pelvis and lower spine) consistent with stress (a stress fracture was not documented).  Repeat X-rays on 11 October 2005 showed a probable old mid-sacral fracture, but no acute findings consistent with a stress fracture.  In physical therapy the same day, the CI was noted to have full range of motion (ROM) without pain and a normal gait.  One week later it was noted that he completed a 4 mile ruck march without recurrent symptoms.  In primary care on 2 November 2005, he was noted to have full and painless ROM of the left hip.  His gait and stance were normal.  However, he was noted to still be symptomatic and crutches were continued.  (The panel recognized the inconsistencies in the above narrative; the history is not entirely consistent in the STRs).  On 10 November 2005, he was noted to have pain fee motion of the left hip without tenderness.  However, 1 month later both tenderness and painful motion were again present.  Repeat X-rays of the left hip were again normal on 5 January 2006.  

The 24 January 2006 MEB NARSUM examination, 1 month prior to preparation of the NARSUM on 27 February 2006, 2 months prior to separation the CI noted complaints of ongoing pain despite treatment.  On examination, he walked without crutches but had an abnormal gait due to pain.  The ROM of both hips was less than VA normal values other than extension on the right, but more limited on the left than right for all measurements.  In degrees, with VA normal values in parenthesis, the values were: flexion 112 (125); extension 17 (20); adduction 32 (45); abduction 39 (45); external rotation 32 (45); and internal rotation (NA).  Motion was limited by pain.  Tenderness over the hip was present on the left.  

The PEB rated the left hip pain and right knee pain conditions 10%, coded 5099-5003), citing the US Army Physical Disability Agency (USAPDA) pain policy.  The panel adjudicated the left hip and right knee conditions IAW the VASRD in effect at the time of separation.  There was no VA examination in evidence.  

The panel first considered if the left hip was separately unfitting when decoupled from the right knee.  The left hip was profiled, implicated in the commander’s statement, and judged to fail retention standards.  The panel determined that the evidence supported a determination that the left hip be found separately unfitting.  It then directed attention to its rating recommendation based on the above evidence.  The panel considered the codes specific for the hip including 5250 (ankylosis), 5251 (limitation of extension), 5252 (limitation of flexion), 5253 (impairment of the thigh), and 5255 (impairment of the femur).  None supported a compensable rating without application of VASRD §4.59 (painful motion) which supported a 10% rating under several codes.  A 10% rating is supported for limited and painful motion with radiographic changes (stress changes on the bone scan).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel observed that the evidence supported a disability rating of 10% for the left hip pain condition, coded 5003, separate from the right knee pain.  

Chronic Pain Right Knee.  The bone scan accomplished on 6 October 2005 for the left hip also noted that there was slightly increased uptake on the right medial (inside) plateau compared to the left knee.  A possible stress reaction was noted, but it was also observed that the CI was young and the growth plates had recently closed.  Clinical correlation was recommended.  In primary care on 2 November 2005, the right knee was noted to be normal as were the gait and stance.  An X-ray on 5 January 2006 was normal.  At the physical therapy appointment on 2 February 2006, the extension was 0 degrees left and right (normal) and 132 and 136 degrees, left and right, with 140 degrees normal for VA purposes.  He reported increased pain with weight bearing.  A review of the records showed no clinical visits specific for the right knee and no mention of right knee pain prior to the bone scan.  No mention was made by the commander concerning the right knee.  It was included in the profile and noted to fail retention standards by the MEB.  The MEB NARSUM recorded that the CI developed pain in the right knee while using crutches (for non-weight bearing of the left hip).  He had a painful gait on examination and the ROM was limited by pain.  It was noted that the left hip was the more debilitating of the 2 conditions.  The knee was stable without swelling or signs of inflammation.  

The panel considered if the knee was separately unfitting.  X-rays were negative and the bone scan showed a possible stress reaction (not a stress fracture).  The CI was asymptomatic until he was issued crutches for the left hip.  While it was cited in the MEB and profile, no diagnosis was made and the commander made no mention of it.  The panel also noted that there were no clinical visits specific for the knee pain condition in evidence.  The evidence does not support a finding that the right knee pain condition was unfitting independent of the left hip condition.  Accordingly, a separate disability rating at separation is not recommended.  The panel observed that while a separate rating for the left hip can be supported by the evidence, this provided no benefit to the CI.  Therefore, no change in the PEB adjudication is recommended.  

BOARD FINDINGS:  In the matter of the chronic pain, left hip and right knee, condition 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 20150920, w/atchs
Exhibit B.  Service Treatment Record

AR20170012628, XXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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,					      
						      					
Enclosure