RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00853
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20081201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Computer Systems Programmer Craftsman, medically separated for “right hip pain” and “right knee pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20081010	VARD - 20081209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Hip Pain Status Post Femur Fracture 	5099-5003	10%	Right Hip Strain 	5252	10%	20081209	
Chronic Right Knee Pain Status Post Femur Fracture	5099-5003	10%	Right Knee Condition with Patellofemoral Syndrome 	5260	0%	20081209	
Obstructive Sleep Apnea, Controlled with CPAP	Cat II	Obstructive Sleep Apnea	6847	50%	20081209	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Right Hip Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s hip condition began in 2006 when he sustained a closed right mid-shaft femur fracture while playing soccer on 24 January 2006.  He underwent surgical pinning the next day.  The CI continued to report hip pain aggravated by activity, especially running.  Serial imaging following surgery showed a well-healed femur fracture with intact surgical hardware (medullary nail).  

The 24 July 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic right leg pain, aggravated by walking or running any distance.  Physical examination showed a normal gait and stance.  Hips were described as “showed no abnormalities.”  The examiner indicated the CI was not world-wide deployable due to pain with walking or running.  

Physical therapy measured hip range of motion (ROM) for the MEB on 7 August 2008.  After three repetitions, hip flexion was 94 degrees (normal 125), extension 9 degrees (normal 30), and abduction 19 degrees (normal 45).  The therapist indicated that motion was not limited by pain.  

At the 9 December 2008 VA Compensation and Pension (C&P) examination, 1 week after separation, the CI reported chronic right hip pain without flare-ups and use of a cane for walking.  Physical examination showed an antalgic gait.  There was normal muscle strength on the right, without atrophy.  There was no joint swelling, muscle spasm, tenderness or laxity.  Neurologic examination of the right lower extremity was normal.  Right hip ROM was flexion of 80 degrees, extension of 30 degrees and abduction was normal, with painful motion.  The CI was able to cross his legs and toe out greater than 15 degrees.  There was no additional loss of motion with repetitive use.  Right femur and hip X-rays noted a healed fracture with intact surgical hardware. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right hip condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing the VASRD.  The VA also rated the right hip condition 10%, analogously coded 5252 (limitation of flexion of thigh), based on the C&P examination, citing ROM limited by pain.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of thigh flexion or extension, or thigh impairment (5251, 5252, 5253).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) coded 5299-5252, noted at the C&P examination, just 1 week after separation.  A 10% rating was also supported for slight hip or knee disability coded analogous to malunion of the femur (5255-femur impairment).  There was no evidence of moderate hip disability, femur nonunion, false joint, or need for a brace for a higher rating under 5255.  The examinations proximate to separation did not demonstrate the presence of hip ankylosis or flail hip joint (5250, 5254) for a rating under the respective codes.  There was therefore no higher than a 10% rating supported for the hip condition under any applicable VASRD §4.71a code.  Although panel deliberations arrived at a 10% rating recommendation utilizing a different code than the PEB, there is no rating benefit to the CI and therefore no change to the PEB’s coding choice is recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right hip condition.  

Chronic Right Knee Pain.  According to the STR and MEB NARSUM, the CI’s knee condition began in January 2006 after he underwent surgical repair of the mid-shaft femur fracture described above.  Following the surgery, imaging showed the fracture was healing well with intact hardware, but the CI reported continued knee pain.  In September 2006, the CI reported pain, aggravated by running, mostly around the palpable screw heads just above the level of the knee and the screws were subsequently removed.  At an orthopedic follow-up visit on 19 December 2007, the CI reported no pain over the fracture site or with ambulation, but he did report knee pain with running.  The physical examination showed a normal gait.  The incisions were well-healed.  There was no effusion, crepitus, mechanical findings or instability.  There was normal knee ROM.  The orthopedic specialist commented that the CI may have early post-traumatic degenerative joint disease of the knee.  

The MEB NARSUM examination noted complaints of knee pain aggravated by walking or running.  Physical examination showed a normal gait and stance.  Knees were described as “showed no abnormalities.”  Physical therapy measured knee ROM for the MEB on 7 August 2008.  After three repetitions, right knee flexion was 132 degrees (normal 140) and extension was normal.  The therapist indicated that motion was not limited by pain.  

At the C&P examination the CI reported chronic right knee pain, without flare-ups, and use of a cane for walking.  Physical examination showed an antalgic gait.  There was normal muscle strength on the right, without atrophy.  There was no joint swelling, muscle spasm, tenderness or laxity.  Neurologic exam of the right lower extremity was normal.  Right knee ROM was normal with pain at end ROM.  There was no additional loss of ROM with repetition.  Right knee X-rays showed no gross abnormality.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the knee condition 10%, analogously coded 5099-5003, citing the VASRD.  The VA rated the knee condition 0%, analogously coded 5260 (limitation of flexion of leg), based on the C&P examination, citing full ROM of the right knee.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of knee flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) coded as 5299-5260.  There was no history or evidence 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 those codes.  A 10% rating was also supported for slight hip or knee disability coded analogous to malunion of the femur (5255).  There was no evidence of moderate knee disability, femur nonunion, false joint or need for a brace for higher rating under 5255.  There was no fracture of the tibia to support consideration under the code for knee impairment related to tibia/fibula conditions (5262).  There was therefore no higher rating than the 10% supported for the knee condition under any applicable code.  Although panel deliberations arrived at a 10% rating recommendation utilizing a different code than the PEB, there is no rating benefit to the CI and therefore no change to the PEB’s coding choice is recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.  

The panel noted that under 5255, only one rating is assigned for “hip or knee disability” related to femur impairment.  Therefore, a single 10% rating for “slight hip or knee disability” or a single 20% rating could be recommended for “moderate hip or knee disability,” but the panel consensus was that the hip or knee disability could not be characterized as “marked” to support a 30% rating recommendation, and therefore, no change to the PEB’s adjudication would be recommended with alternative use of the 5255 code.  

Contended PEB Condition:  Obstructive Sleep Apnea, controlled with CPAP.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  There were no limitations noted on limited duty forms attributable to OSA.   The contended condition was not implicated in the commander’s statement or judged to fail retention standards.  The MEB NARSUM determined the CI had “well-controlled sleep apnea” that “should not affect his ability to perform his job or be deployed.”  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended. 

BOARD FINDINGS:  In the matters of the right hip and right knee conditions and IAW VASRD §4.71, the panel recommends no change in the PEB adjudications.  In the matter of the contended obstructive sleep apnea, the panel recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-00853.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings