RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-01252
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Administrative Specialist, medically separated for “left hip and left knee pain” with a disability rating of 0%.  

CI CONTENTION:  “Both knees, right shoulder, neck, back, anxiety, depression, asthma, TBI, left hip, headaches and PTSD.”   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 - 20051215	VARD - 20070403	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Hip and Left Knee Pain	5099-5003	0%	Status Post Meniscus Tear	5299-5259	0%	20060531	
			Chronic Left Hip Pain	5099-5003	0%	20060531	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Left Hip and Left Knee Pain.  The PEB combined left hip and left knee conditions under a single disability rating, coded 5099-5003 (analogous to degenerative arthritis) and rated 0%, with application of the US Army Physical Disability Agency pain policy.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and that 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 VASRD 5003 rating criteria, 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.  The evidence for the left hip and left knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Left Knee.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI developed left knee pain with a contusion (bumped on a steering wheel getting into car) in April 2004.  The pain persisted and worsened over time, but imaging (X-ray, MRI) was normal.  Multiple provider entries in the STR documented grossly normal range of motion (ROM), with occasional note of painful motion, and there were none that indicated any significant ROM limitation.  There were five entries that recorded measured ROM, with flexion ranging from 110 to 130 degrees (normal 140) and all noting 0 degrees extension (normal).  There was ample STR documentation of the absence of effusion, impingement (objective locking), or instability.  There was frequent documentation of an antalgic gait favoring the left leg, although some examiners noted a normal gait.  

Of note, the majority of STR provider entries were directed only at the knee, with the hip condition surfacing as a concurrent complaint in a few notes.  The STR provider evidence indicated that the MEB referral was for the left knee condition only.  That notwithstanding, the MEB’s DA Form 3947 submission combined “recurrent left knee pain and hip pain” as a single condition failing retention standards.  The permanent L3 profile specified “left hip and knee pain.”  The commander’s performance statement was not probative to separate fitness implications of either condition.

The 12 September 2005 MEB NARSUM examination, 6 months prior to separation, documented “intractable left knee pain...worsened over this past year” that was aggravated by prolonged sitting or standing, and prohibited running and multiple general soldiering requirements.  The physical examination recorded a normal gait (as did a clinical note 6 days earlier) and strength, and no tenderness, effusion, instability, impingement, or atrophy.  The NARSUM examiner recorded normal ROM with flexion to 140 degrees and extension to 0 degrees, without comment regarding painful motion.  Painful motion was documented on the MEB’s DD Form 2808 one week later on 20 September 2005.  Formal ROM measurements taken for the MEB on 28 September 2005 were forwarded as an addendum to the Medical Board; and, were in marked contrast with all other ROM evidence.  The examiner recorded flexion to 55 degrees and minus 5 degrees extension, specifying limitation by pain.

The 31 May 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, documented non-specific left knee pain (without note of subjective locking or instability) that rendered the CI unable to run.  The examiner stated that “he is able to walk approximately half a mile, but does so with a limp,” but did not address whether a gait disturbance was present.  The physical examination recorded “slight crackling without crepitus or instability” with no note of tenderness or effusion.  Measured flexion and extension were again normal, specifying the absence of painful motion and no ROM degradation with repetition.  The VA examiner detected joint impingement by examination (positive McMurray sign) and diagnosed a meniscal tear, but an MRI on 4 June 2006 demonstrated intact menisci with “early” degenerative changes only.

Directing attention to its recommendations, the panel first considered if the left knee condition was reasonably justified as separately unfitting as elaborated above.  The panel noted that the STR evidence indicated the left knee was the primary indication for an MEB referral.  It was listed on the profile and determined, along with the hip, to fail retention standards.  Although not implicated directly in the commander’s statement, it was implicated as the cause of significant functional limitations in the NARSUM.  The panel thus agreed that it was justified as separately unfitting under the above standards.

Having agreed that separate rating was indicated, the panel turned to deliberation of the appropriate coding and rating recommendation.  The VA rated the left knee condition 0%, coded 5299-5259 (analogous to persistent symptoms after cartilage removal).  While members agreed the VA’s code was dubiously applicable, its 0% rating was an accurate reflection of the C&P evidence with normal ROM, no painful motion, and no other ratable findings.  There was no ROM limitation in evidence, even from the inexplicably worse measurements from the MEB addendum, to support the minimum 10% rating under the applicable codes (5260, 5261).  Members agreed, however, that there was satisfactory evidence of painful motion from the service evidence to support a minimum 10% rating IAW VASRD §4.59.  As noted above, code 5259 was not clinically applicable, nor does it offer a rating higher than 10%.  There was no evidence of instability (5257), frequent locking with recurrent effusions (5258), or 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).  There were no other criteria in evidence to support a rating higher than 10% under any applicable VASRD §4.71a code.  After due deliberation, considering all evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends the left knee condition as separately unfitting with a 10% rating under code 5299-5260 (analogous to limitation of flexion), justified by satisfactory evidence of painful motion (MEB Addendum, corroborated by the MEB’s DD Form 2808 physical examination and other STR provider documentation).  

Left Hip.  The CI attributed left hip pain to the same 2004 injury associated with the knee pain, although, the complaint did not surface in STR provider notes until months later.  Imaging (X-ray, bone scan) was normal and no clear etiology was identified.  There was mention of painful motion of both hips in some STR entries, although there were none that indicated any significant ROM limitation or that provided any probative ROM measurements (preceding those below).  There was STR documentation of an antalgic gait before the complaint of hip pain surfaced, and no subsequent evidence for clarifying the contribution (if any) of hip pain to the antalgic gait.  There was no documentation of any other VASRD-ratable findings.

The NARSUM documented nonspecific left hip pain “with no obvious etiology” developing in conjunction with worsening of the knee pain.  There were no documented functional limitations distinct from those elaborated above for the knee condition.  The physical examination did not record any abnormal joint findings and noted normal strength.  Documented ROM was normal or nearly so in all planes by the NARSUM examiner, although as with the knee evidence, hip ROM was significantly and inexplicably reduced in the measurements from the subsequent MEB addendum.
 
The C&P examination documented intermittent left hip pain that “occurs approximately three times a week and will last for half an hour.”  The VA examiner opined that the pain was “not in the joint itself” but was associated with chronic low back pain (not within the panel’s scope of review).  No functional limitations were documented other than a reference to the half-mile walking tolerance noted for the knee.  The physical examination recorded “normal” joint findings with no tenderness.  Measured ROM had returned to normal or near normal in all planes.

Directing attention to its recommendations, the panel first considered if the left hip condition was reasonably justified as separately unfitting.  It was clear in this case that the primary condition leading to MEB referral was the knee condition and there was significant doubt as to whether the hip condition would have independently resulted in DES referral and medical separation.  The well-established principle for fitness determinations is that they are performance-based, and there was no evidence for functional impairment linked exclusively to the hip.  Although the hip may have contributed to the overall functional impairment associated with the knee, the fact remained that the objective functional limitations were the same before and after the hip pain surfaced as a significant complaint.  Furthermore, the C&P evidence, which was temporally closer to separation than the NARSUM and subsequent service evidence, indicated that the hip pain was improving.  It was now intermittent, not directly linked to any functional impairment, benign by examination, and rated 0% by the VA.  This strengthens a conclusion that, had it not been a concurrent complaint during the MEB process for the knee condition, the hip pain would not have prohibited continued military service.  Members ultimately agreed that, in consideration of the preponderance of evidence per the standard elaborated above, there was insufficient performance-based evidence to reasonably justify the left hip condition as separately unfitting; thus, it was not subject to separate service rating.

BOARD FINDINGS:  In the matter of the PEB-combined left knee and left hip conditions, the panel recommends that it be rated for separate conditions as follows:  an unfitting left knee condition coded 5299-5260 and rated 10% IAW VASRD §4.71a, and a left hip condition determined to be not unfitting and not subject to service 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	
Contusion with Intractable Pain, Left Knee	5299-5260	10%	
Chronic Pain of Unclear Etiology, Left Hip	Not Unfitting	
COMBINED	10%	

AR20190004033, XXXXXXXXXX

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Dear XXXXXXXXXX:

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.