RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00976
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20061113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “pain with clinical diagnosis of degenerative arthritis bilateral knees, hips, elbows, hands, and feet” with a disability rating of 20%.  

CI CONTENTION:  He never finished receiving medical treatment before being sent home.  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 - 20060717	VARD – 20071116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain with Clinical Diagnoses of Degenerative Arthritis Both Knees, Bilateral Hips and Elbows, Bilateral Hands, and Bilateral Feet 	5003	20%	Degenerative Arthritis, Left Knee	5260-5003	10%	20060826	
			Status Post Right Knee Arthroscopic Surgery with Synovectomy and Degenerative Arthritis	5260-5003	10%	20060826	
			Degenerative Arthritis, Left Hip	5003	0%	20060826	
			Degenerative Arthritis, Right Hip	5003	0%	20060826	
			Degenerative Arthritis, Left Elbow	5003	0%	20060826	
			Degenerative Arthritis, Right Elbow	5003	0%	20060826	
			Degenerative Arthritis, Left Hand	5003	0%	20060826	
			Degenerative Arthritis, Right Hand	5003	0%	20060826	
			Degenerative Arthritis, Left Ankle, Foot and Toes	5003	0%	20060826	
			Degenerative Arthritis, Right Ankle, Foot and Toes	5003	0%	20060826	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	
ANALYSIS SUMMARY:  

Pain with Degenerative Arthritis of Bilateral Knees, Hips, Elbows, Hands, and Feet.  The PEB combined the knee, hip, elbow, hand, and foot conditions under a single service disability rating, coded analogously to 5003 (arthritis, degenerative) and rated 20% with application of the US Army Physical Disability Agency 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.  

Bilateral Knee Degenerative Arthritis. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s degenerative arthritis of the knees, hips, elbows, hands, and feet began in approximately 2003 as increasing joint discomfort. On 13 October 2004, a physical therapy (PT) note indicated the CI had a mildly antalgic gait with a 1+ effusion of the right knee and tenderness of the anteromedial joint line, but full range of motion (ROM) with good quadricep function. Right knee X-rays on 5 January 2006 and an MRI on 21 January 2006 demonstrated patellar bone spur formation, tricompartmental osteoarthritis, a medial meniscus posterior horn tear and degeneration, a moderate joint effusion, and tricompartmental chondromalacia with medial and lateral compartment full thickness abnormalities.  On 25 January 2006, PT assessed the right knee pain condition as compression arthralgia of the knee/patella/tibia/fibula and osteoarthritis.  On 3 February 2006, an orthopedist documented right knee pain for over a year which was worsened with jumping and especially squatting.  At a rheumatology visit on 21 March 2006, the CI reported he had some osteoarthritis with discomfort involving the elbows, lower back, knees, and feet with periodic swelling.  On examination, there was 1+ effusion on the right knee with lack of full extension. The examiner assessed generalized osteoarthritis “with the possibility of a bone forming diathesis [predisposition] such as diffuse idiopathic skeletal hyperostosis [excessive bone growth].”  Left knee X-rays on 7 April 2006 demonstrated a 2.5 x 1.0 cm bony fragmentation at the anterior left tibial tuberosity suggestive of Osgood-Schlatter disease.    

During the 4 April 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported generalized arthritis including the knees.  Physical examination showed painful bilateral knee ROM.  The 7 April 2006 MEB NARSUM examination noted complaints of increasing knee joint discomfort over the prior 3 years.  Physical examination showed a 1+ effusion and “lack of full extension” on the right.

At the 10 May 2006 PT evaluation, the provider documented that the CI was “post op knee arthroscopic debridement, performed on the economy,” and presented on crutches with ports bandaged.  Active right knee ROM was 11-85 degrees (normal 0-140) with a circumference at the right mid-patella of 44 cm compared to 41 cm on the left.  On 15 May 2006, the PT examiner annotated “AAROM 2-117, AROM 2-90” with no further specifications.  

Left knee X-rays on 19 May 2006 demonstrated bilateral mild tricompartmental osteoarthritis and enthesophyte (abnormal bony projections at tendon or ligament attachment) formation, suggestive of idiopathic skeletal hyperostosis.  During a PT visit the same day, right knee ROM was 1-105 degrees.  

At the 26 August 2006 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported generalized arthritis with random flare-ups associated with weather changes and cold, damp conditions.  Physical examination showed mild swelling in both knees and bilateral ROM measurements lacked 15 degrees of flexion and extension.  At the 5 November 2007 VA C&P examination, 12 months after separation, the CI reported that his right knee “hurts all the time and flares up.”  Physical examination showed right knee flexion to 110 degrees with pain, and limitation of motion at 100 degrees with repetition; extension was 90 to 10 degrees with pain at the endpoint.  Left knee flexion was to 120 degrees with pain, and limitation of motion at 110 degrees; extension was 90 to 10 degrees with pain at the endpoint.  

The panel first deliberated whether the bilateral knee degenerative arthritis, when considered alone, was unfitting for continued military service, and concluded that only the right knee would have caused the CI to be referred into the DES and been determined to be unfit.  Members agreed that the evidence showed limited left knee treatment.  Although there were findings of Osgood-Schlatter disease and arthritic changes on later X-rays, the panel determined the left knee to be not separately unfitting.

The panel next directed attention to its rating recommendation based on the above evidence.  The PEB applied a single 20% rating, coded 5003, for the bundled conditions mentioned above.  The VA rated the right knee condition 10%, coded 5003, based on the C&P examination, citing chronic right knee pain, arthroscopic surgery with synovectomy and removal of loose bodies, and objective evidence of right knee swelling.  The VA rated the left knee condition 10%, coded 5003, citing subjective complaints and objective evidence of left knee swelling.  Panel members agreed there was no limitation of motion which supported a rating under the diagnostic codes for 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).  There was persistent pain after meniscal surgery which also warranted a 10% rating under code 5259 (cartilage, semilunar, removal of symptomatic), however this provided no benefit to the CI.  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), and no fracture, nonunion 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 a disability rating of 10% for the right knee degenerative arthritis condition, coded 5099-5003.  

Bilateral Hip Degenerative Arthritis.  The CI’s bilateral hip condition began in June 2004 after pulling his right hamstring while sprinting.  At a PT visit on 15 June 2004, the CI reported hip pain aggravated by running, prolonged weight bearing, and bending over.  On examination, the lower extremity posture was within normal limits and bony landmarks level bilaterally, however, there was an antalgic gait of the right lower extremity.  Measured ROM was full in all planes, with slight pain during right hip extension, and no pain during right leg extension/flexion.  Strength was 5/5 for right hip and leg extension, and 4+/5 during leg flexion, with some pain.  While there was right medial hamstring belly tenderness, none was noted near the right medial/lateral hamstring tendons.  Tests to determine hip pathology (FABER and Scour) were negative bilaterally.  The 21 March 2006 rheumatology examination revealed mild lack of rotation, and X-rays the same day showed findings most consistent with moderate osteoarthritis involving both hips.  A cortical bone hypertrophic process could not be completely excluded.  

During the MEB examination, the CI reported generalized arthritis including the hips.  Physical examination showed pain with bilateral hip ROM testing.  The MEB NARSUM examiner noted complaints of increasing joint discomfort and documented “mild lack of hip rotation.”  

At the 26 August 2006 C&P examination, the CI reported generalized arthritis including the hips.  Physical examination showed normal posture and gait, and no swelling, redness or deformities.  The provider stated “full range of motion is evident in most joints.”  At the 5 November 2007 C&P examination, the CI complained of joint pain.  The examiner recorded hip ROM measurements, in degrees, as:  bilateral hip flexion to 90 (normal 125), bilateral extension to 15 (normal 20), right hip abduction to 30 (normal 45), and left hip abduction to 35, with pain at endpoints of motion in all planes; bilateral adduction was to 15 (normal 25).  

The panel deliberated whether the bilateral hip degenerative arthritis, when considered alone, was unfitting for continued military service, and concluded the evidence did not show that either hip would have caused the CI to be referred into the DES or be found unfit, but for the fact that he had moderate osteoarthritis demonstrated by X-rays.  After due deliberation, considering all of the evidence, the panel concluded that the bilateral hips were not unfitting and no rating is warranted for the bilateral condition or for either hip individually.

Bilateral Elbow Degenerative Arthritis.  The CI’s bilateral elbow condition began in 2003 without trauma or injury.  The 21 March 2006 rheumatology evaluation revealed a mild lack of full extension bilaterally, but no synovitis.  On the same day, X-rays showed large olecranon enthesophytes and mild marginal hypertrophic changes along the coronoid process and trochlear regions of the humerus bilaterally.   During the MEB examination, the CI reported generalized arthritis including the elbows, and physical examination showed painful elbow ROM.  The MEB NARSUM examination noted complaints of increasing joint discomfort over several years involving both elbows.  Physical examination showed the elbows to have no synovitis and a mild lack of full extension bilaterally.

At the 26 August 2006 C&P examination, the CI reported generalized arthritis including the elbows.  Physical examination showed no redness, tenderness, or swelling, and a lack of about 15 degrees extension in both elbows.  At the 5 November 2007 C&P examination, the provider recorded ROM, in degrees, as:  right elbow flexion to 145 (normal), extension to 0 (normal), and pronation and supination to 70 (normal 80 and 85, respectively).  Left elbow flexion was to 140 and extension to 0, with pronation to 70 and supination to 75.  Pain was noted at the endpoints of motion in all planes.

The panel deliberated whether the bilateral elbow degenerative arthritis, when considered alone, was unfitting for continued military service, and concluded the evidence did not show that either elbow condition would have caused the CI to be referred into the DES or be found unfit, but for the fact that he had generalized osteoarthritis with X-rays demonstrating olecranon enthesophytes and mild marginal hypertrophic changes.  After due deliberation, considering all of the evidence, the panel concluded that the bilateral elbows were not unfitting, and no rating is warranted for the bilateral condition or each elbow individually.

Bilateral Hand Degenerative Arthritis.  The CI’s bilateral hand condition began in 2003 without trauma or injury.  Rheumatology evaluation on 21 March 2006 revealed mild osteoarthritis changes of the right fifth proximal interphalangeal (PIP) joint, and X-rays the same day showed minimal dorsal hypertrophic changes present at the distal phalanx and bases consistent with osteoarthritis.  No other significant soft tissue, joint or osseous abnormality was identified.  

During the MEB examination, the CI reported generalized arthritis including the fingers, and physical examination showed painful ROM of the fingers.  The MEB NARSUM examination noted complaints of increasing joint discomfort and the examiner documented mild osteoarthritis changes of the right fifth PIP joint. 

At the 26 August 2006 C&P examination, the CI reported generalized arthritis of the hands, but the examiner noted no redness, tenderness, or swelling.  At the 5 November 2007 C&P examination, the CI reported arthritis and flare-ups with excessive repetitive hand motions.  Physical examination showed stiffness with full ROM of the left and right hands.

The panel deliberated whether the bilateral hand degenerative arthritis, when considered alone, was unfitting for continued military service, and concluded that the evidence did not show that either hand would have caused the CI to be referred into the DES or be found unfit, but for the fact that X-rays demonstrated minimal hypertrophic changes consistent with osteoarthritis.  After due deliberation, considering all of the evidence, the panel concluded that the bilateral hands were not unfitting, and no rating is warranted for the bilateral condition or either hand individually.

Bilateral Foot Degenerative Arthritis.  On 28 November 2005, the CI sought medical treatment for right heel pain that had been ongoing for a year with walking or running.  Right foot X-rays on 27 January 2006 demonstrated severe enthesopathy of the calcaneus with spur formation at the plantar calcaneal junction and the Achilles tendon insertion.  Enthesophyte formation was also present on the ventricular and talar neck as well as at the base of the fifth metatarsal and at the distal fibula.  There was moderate degenerative change at the first metatarsophalangeal (MTP) and interphalangeal joints as well as the proximal PIP joint of the fifth toe.  

At a podiatry visit on 6 March 2006, the CI complained of bilateral foot and ankle pain. On examination, there was tenderness of the posterior heels with prominent exostoses (bone spurs), right greater than left.  There was pain in the third interspace of the left foot with Tinel’s testing (to determine nerve root irritation), and into the third and fourth digits when the foot was squeezed. Bilateral ROM of the subtalar, ankle and first MTP joints was limited.  Rheumatology evaluation on 21 March 2006 revealed mild pes planus, bilateral tenderness of the distal Achilles, no significant plantar discomfort, and dry fissured skin of the heels.  At follow-up podiatry appointments in May and June 2006, resection of the calcaneal spur was discussed and the CI was given two steroid/anesthetic injections for left foot neuritis of the third interspace.

The CI had surgery to remove the right foot heel spur on 23 June 2006 and complained of numbness post-operatively.  At a follow-up on 23 July 2006, the podiatrist noted a well-healed incision without erythema or drainage.  Sutures were intact and there was no edema or sensory deficit to the foot/heel, and minimal tenderness. The CI underwent PT in accordance with an Achilles tendon repair postoperative protocol.  

During the MEB examination, he reported generalized arthritis and bone spurs in both feet.  Physical examination showed tenderness over the right calcaneus and painful bilateral ankle ROM.  The MEB NARSUM examiner noted complaints of increasing foot joint discomfort, and documented mild pes planus, tender Achilles tendons bilaterally, and no plantar discomfort.

At the 26 August 2006 C&P examination, the CI complained of arthritis of the feet and ankles and continued right heel pain after surgery.  Physical examination showed no redness, tenderness, or swelling, and full ROM in both ankles and feet, and all toes.  At the 5 November 2007 C&P examination, the CI reported that he broke the proximal phalanx of his left third toe while in basic training and developed a bone callus “that did not shave down.”  He related that he would have to take off his shoe to “pop” his foot when it locked up.  The CI also complained of bone spur pain on the sides of the right heel and along the arch.  Physical examination showed a normal stride upon walking; however, upon starting and stopping his walk, he displayed an antalgic gait.  The examiner noted the surgical removal of the right osteophyte was not successful and that it was growing back.  The bone callus of the proximal phalanx of the left third digit caused moderate to severe foot pain, and there was abnormal wear on the inside of the forefoot on both shoes.  Bilateral PIP and MTP joint ROM was 0-15 degrees and 0-10 degrees, respectively, with pain noted at the endpoints of all motions.   The panel first deliberated whether the bilateral foot degenerative arthritis, when considered alone, was unfitting for continued military service, and concluded that the condition would have caused the CI to be referred into the DES and been determined to be unfit.  

The panel next directed attention to its rating recommendation based on the above evidence.  The PEB applied a single 20% rating, coded 5003, for the bundled conditions mentioned above. The VA rated the left and right foot conditions 0% each, coded 5003, based on the C&P examination, citing “a noncompensable evaluation is assigned unless there is objective evidence of painful or limited motion of a major joint or group of minor joints, or multiple joint involvement.”  On 10 June 2008, the VA subsequently rated the left ankles and feet (to include toes) 10%, coded 5003-5271 (arthritis, degenerative-ankle, limited motion of), effective on the date of separation.  The VA also rated the status post right heel calcaneal spur removal 0%, coded 5284 (foot injuries, other), and the left foot stress fracture 0%, coded 5284 (this was revised on 3 October 2008 to a 10% rating for left foot stress fracture with painful neuroma).

Members noted the CI had not only bilateral arthritic changes of the feet, but also underwent a spur removal of the right foot calcaneus/Achilles tendon that remained painful postoperatively and then recurred.  Although details in the STR were sparse related to the left foot, the CI had a series of steroid/anesthetic injections at the site of residual callus formation from a prior fracture of the third toe. The panel agreed that his permanent profile restrictions for running and walking as well as difficulties with duty performance, as implicated in the commander’s statement, warranted separate ratings for the unfitting right and left foot conditions at the time of separation.  Upon deliberation, members noted each foot could be coded 5284 and rated 10%.  Alternatively, the left foot could be coded 5279 (metatarsalgia, anterior (Morton’s disease), unilateral, or bilateral) at 10%, and the right foot coded 5284 at 10%.  Since there was no weakness, use of code 5277 (weak foot, bilateral) was not applicable.  After due deliberation, considering all of the evidence, the panel recommends a disability rating of 10% for the right foot condition, coded 5284, and 10% for the left foot condition, coded 5284.

BOARD FINDINGS:  In the matter of the bilateral knee degenerative arthritis condition, the panel recommends an unfitting right knee with a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the bilateral foot degenerative arthritis condition, the panel recommends an unfitting left foot and unfitting right foot with a disability rating of 10% each, coded 5284 IAW VASRD §4.71a.  In the matter of the degenerative arthritis of the left knee, bilateral hips, and bilateral elbows, the panel recommends the conditions to be not unfitting.  There are no other conditions within the panel’s scope of review for consideration.   

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Degenerative Arthritis, Right Knee	5099-5003	10%	
Degenerative Arthritis, Right Foot	5284	10%	
Degenerative Arthritis, Left Foot	5284 	10%	
COMBINED w/ BLF	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170210, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008597, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs. 

Sincerely,					      
Enclosure