RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00489
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Telecommunications Terminal Device Repairer, medically separated for “chronic pain, bilateral knees, right shoulder and left hip,” 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 - 20041012	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Bilateral Knees, Right Shoulder and Left Hip	5099-5003	10%	No VA examination in evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Pain, Bilateral Knees, Right Shoulder and Left Hip.  The PEB combined the chronic bilateral knee pain, right shoulder pain and left hip pain conditions under a single disability rating, coded 5099-5003 (analogous to arthritis, degenerative) and rated 10% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  This 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 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 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 bilateral knee pain, right shoulder pain and left hip pain conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Chronic Bilateral Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain began in January 2002 after stepping in a whole and falling on both knees.  Since that time she complained of grinding and popping in both knees.  

At the 9 July 2004 orthopedics examination, 5 months prior to separation, the CI reported bilateral knee pain, left greater than right.  Physical examination showed range of motion (ROM) of flexion to 140 degrees (normal) and extension to 0 degrees (normal) bilaterally.  The examiner noted the strength of the left quadriceps muscles to be 3+/5 (able to extend against gravity but not able to overcome additional resistance) and the right quadriceps muscles 4/5 (able to overcome some resistance from the examiner but yields to full resistance) and bilateral quadriceps atrophy was observed.  

The 15 September 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral knee pain limiting her ability to run more than one-half mile or to stand in the same position for more than 20 minutes.  Physical examination showed range of motion (ROM) of the right knee flexion to 104 degrees (normal 140) and extension to 0 degrees (normal) left knee flexion was to 106 degrees (normal 140) and extension to 0 degrees (normal).  All ROM measurements were limited by pain.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel first considered if the left knee pain condition and the right knee pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel noted that the CI was on continuous profile beginning October 2003 and that with the exception of a two week period the activity limiting profile was for both knees.  The majority of the clinic visits in the 2 years prior to separation were for both knees and the commander’s impact statement implicates both knees without stressing one over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with return to military training, members agreed that each knee was reasonably justified as separately unfitting.  The PEB rated the bundled bilateral knee, right shoulder and left hip condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy.  

The panel next addressed ratings for each unfitting knee.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) in either knee.  However, there was evidence of pain with limited motion and functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each knee.  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 and mindful of VASRD §4.3 (reasonable doubt), the panel recommends that each knee be unfitting with a disability rating of 10% for the left knee pain condition and 10% for the right knee pain condition, each coded 5099-5003.  

Chronic Right Shoulder Pain (Rotator Cuff Impingement).  According to the STR and the MEB NARSUM, the CI’s right shoulder pain condition began in March 2004 after falling during combative training and landing on her shoulder.  The 15 September 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of right shoulder pain with push-ups and lifting.  Physical examination showed flexion to 130 degrees (normal 180) and abduction to 145 degrees (normal 180).  Impingement signs were present and the CI guarded for load-shifting tests but there was no evidence of pain with active motion.  

The panel directed attention to its rating recommendation based on the above evidence.   The panel then considered if the right shoulder pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel found no clinical visits for right shoulder pain prior to the MEB NARSUM visit, it was not implicated in the commander’s impact statement and both the permanent profile and the memo completed by the attending physician to start the MEB dated 9 July 2004 listed only bilateral knee pain as unfitting.  The first profile to mention right shoulder pain was dated 28 September 2004, after the MEB NARSUM.  The panel members concluded that the preponderance of evidence showed the right shoulder pain condition would not have caused the CI to be referred into the DES or to be found unfit.  The PEB rated the bundled bilateral knee, right shoulder and left hip condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy.  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 an additional rating for the right shoulder pain condition.  

Chronic Left Hip Pain.  According to the STR and the MEB NARSUM, the CI’s left hip pain condition began in July 2003 with gradual onset of pain without any reported injury or trauma.  The 15 September 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of left hip pain that is increased with sit-ups, flare kicks and running.  Physical examination showed flexion to 58 degrees (normal 125), external rotation 45 degrees (normal) with pain at the extremes of motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel finally considered if the left hip pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel found no clinical visits for left hip pain prior to the MEB NARSUM visit, it was not implicated in the commander’s impact statement and both the permanent profile and the memo completed by the attending physician to start the MEB dated 9 July 2004 listed only bilateral knee pain as unfitting.  The first profile to mention left hip pain was dated 28 September 2004, after the MEB NARSUM.  The panel members concluded that the preponderance of evidence showed the left hip pain condition would not have caused the CI to be referred into the DES or to be found unfit.  The PEB rated the bundled bilateral knee, right shoulder and left hip condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy.   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 an additional rating for the left hip pain condition.  

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain, right shoulder pain and left hip pain conditions, the panel unanimously recommends that it be adjudicated for four separate conditions:  In the matter of the bilateral knee pain condition, the panel unanimously recommends separate disability ratings of 10% for each, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right shoulder pain condition, the panel unanimously agrees that it cannot recommend a finding of unfit for additional a disability rating.  In the matter of the left hip pain condition, the panel unanimously agrees that it cannot recommend a finding of unfit for additional a disability rating.  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	
Chronic Left Knee Pain	5099-5003	10%	
Chronic Right Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160807, w/atchs
Exhibit B.  Service Treatment Record

AR20170015709, 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