RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00219
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20041104

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Tow Dragon Repairer, medically separated for “osteoarthritis of the right hip and right knee” with a disability rating of 10%.

CI CONTENTION:  Contends degenerative joint disease, right hip and osteoarthritis, right knee.  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 - 20040805	VARD - 20050430	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Osteoarthritis of the Right Hip and Right Knee	5003	10%	Degenerative Joint Disease, Right Hip And Right Knee	5003	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Right Hip and Right Knee.  The PEB combined the osteoarthritis of the right hip and right knee conditions as a single unfitting condition coded 5003 (arthritis, degenerative) 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’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 right hip and right knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Right Hip:  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hip condition began in May 2002 after playing football.

At the 5 March 2004 orthopedic examination, 8 months prior to separation, the CI reported 3 years of groin pain.  Physical examination showed sacroiliac joints were not tender.  Motor strength was 5/5.  Hip range of motion was slightly limited; measurements and painful motion were not addressed.

At the 19 March 2004 orthopedic follow-up examination, 8 months prior to separation, the CI reported no specific hip complaints.  Right hip X-rays and CT scan revealed moderate arthritis and bilateral acetabular spurring (ball shaped femoral head (bone) rubs abnormally or does not permit a normal range of motion in the acetabular hip socket) with slight narrowing of the joint line.

On 20 April 2004 the CI was issued a permanent right hip profile prohibiting running, swimming, biking, jumping, or ruck.

The 30 June 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of continued right hip and right knee pain.  Physical examination showed right hip ROM of internal rotation to 20 degrees compared to 40 degrees on the left hip and external rotation to approximately 40 degrees on the right hip and 60 degrees on the left hip.  Bilateral flexion and extension ROM was good with painful motion on the right side.  Right hip X-rays revealed acetabulum (hip socket) degenerative changes.  A CT scan showed osteoarthritis.

At the 28 July 2004 physical therapy examination, 3 months prior to separation, the CI reported chronic pain of the right hip.  Physical examination showed a hip flexion of 100, 110, 120 degrees (125 normal), extension of 12, 12, 15 degrees (20 normal); painful motion was not addressed.

There was no VA examination proximate to separation for the panel to review.

The panel first considered if the osteoarthritis of the right hip condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel majority agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties and accordingly a separate disability rating is recommended.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the osteoarthritis of the right hip and right knee condition 10%, coded 5003 (degenerative arthritis), citing radiographic evidence.  The VA also rated the right hip and right knee conditions 10%, also coded 5003, based on the STR, citing X-ray evidence involving two major joints.

The MEB NARSUM physical noted a right hip decreased internal and external rotation ROM with and good right hip flexion and extension with painful motion on the right side.  Panel majority agreed that the evidence reasonably justified that the functional limitations of the conditions contributed to the CI’s inability to perform his military duties and accordingly a separate disability rating is recommended for the right hip.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5251 or 5252).  There was no limitation of abduction or adduction or rotation that supported a rating under the VASRD diagnostic codes for limitation of motion (5253).  There was no hip flail joint that supported a rating under the VASRD diagnostic code (5254).  There was evidence of sufficient STR evidence of painful motion of the hips with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) for the right hip.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a separately unfit determination with a disability rating of 10% for the right hip condition, coded 5003.

Right Knee:  According to the STR and the MEB NARSUM, the CI’s right knee condition began in May 2002 after playing football.  At the 19 March 2004 orthopedic follow-up examination, 8 months prior to separation, the CI reported no specific knee complaints.  Right knee X-rays revealed moderate arthritis with definite changes of the lateral and patellofemoral joints with spurring and some narrowing.

On 20 April 2004 the CI was issued a permanent right knee profile prohibiting running, swimming, biking, jumping, or ruck.

At the 27 May 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported bilateral knee arthritis with swelling after running.  Physical examination showed medial right knee tenderness.  The 30 June 2004 MEB NARSUM examination, 4 months prior to separation, noted continued complaints of right knee pain.  Physical examination showed full right knee ROM (measurements not provided) with tenderness around the lateral joint space.  Instability testing was negative.  Right knee X-rays showed decreased lateral joint space indicative of osteoarthritis.  

At the 28 July 2004 physical therapy examination, 3 months prior to separation, the CI reported chronic right knee pain.  Physical examination showed ROM of flexion to 125, 123, 127 degrees (140 normal), extension of 0 degrees (0 normal); painful motion was not addressed.

There was no VA examination proximate to separation for the panel to review.

The panel first considered if the osteoarthritis of the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel majority concluded that there was not a preponderance of evidence of the service records that overcame the panel’s presumption that the bundled right knee condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right knee condition at the time of separation.

The panel noted that treatment notes documented right knee pain along with radiographic evidence.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  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) to support a rating under the respective codes.  There was no non-union, or malunion fracture of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, the panel majority concluded that there was sufficient evidence of painful motion and functional loss to support a 10% rating for the right knee IAW §4.59, §4.40 and §4.45.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a separately unfit determination with a disability rating of 10% for the right knee pain condition, coded 5003 (arthritis, degenerative).

BOARD FINDINGS:  In the matter of the osteoarthritis of the right hip condition, the panel majority recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the osteoarthritis of the right knee condition, the panel majority recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Osteoarthritis of the Right Hip 	5003	10%	
Osteoarthritis of the Right Knee	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160411, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170014111, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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 also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure