RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01846
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20050331

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, X-Ray Specialist, medically separated for “chronic back pain” and “chronic pain, right hip and right knee,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  Her back should be rated higher.  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 - 20050119	VARD - 20061005	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5237	10%	Degenerative Joint Disease and Disc Disease of the Lumbar Spine	5242	10%	20050525	
Chronic Pain, Right Hip and Right Knee	5099-5003	10%	Right Patellofemoral Pain Syndrome	5099-5003	10%	20050525	
			Right Hip Pain	5299-5252	NSC	20050525	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began insidiously without specific injury or trauma.  An MRI in October 2004 revealed degenerative disc disease at L3-4 and L5-S1.  The 13 December 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of constant low back pain.  Physical examination showed a normal gait and posture.  There were no muscle spasms.  Range of motion (ROM) was flexion of 85 degrees (normal 90) and combined ROM of 155 (normal 240) degrees with painful motion.  The 5 August 2005 functional capacity evaluation, 4 months after separation, recorded complaints of constant low back pain.  Physical examination revealed normal posture and muscle strength.  “Trunk” flexion was limited by 33% (approximately 60 degrees); combined ROM and painful motion were not recorded.  The examiner noted that the stated pain levels did not correlate with body or facial expressions.

At the 25 October 2005 VA Compensation and Pension (C&P) evaluation, 7 months after separation, the CI reported gradual onset of back pain in September 2003 that gradually worsened over a period of months, aggravated by prolonged sitting or standing, and occasionally radiated to the right leg.  The CI denied incapacitating episodes or bowel or bladder involvement.  Physical examination showed a normal gait and posture.  ROM was normal, but pain increased with repetitive motion.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbar spine strain), citing ROM limited by pain with localized tenderness.  The VA rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the functional capacity evaluation, 4 months after separation, citing limitation of flexion.

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) or combined (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB NARSUM examination; and corroborated by the totality of the STR and VA evidence proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  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 a change in the PEB adjudication for the back condition.

Chronic Pain Right Hip and Right Knee.  The PEB combined the right hip and right knee conditions under a single disability rating, coded analogously to 5003 and rated 10% 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 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 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 STR and the MEB NARSUM, the CI’s right hip pain began in September 2003 while performing physical training.  Initially the pain was mild and intermittent, but was exacerbated by running and gradually progressed to constant-severe pain.  Right hip and femur X-rays and MRI were normal.  Although some examiners opined the diagnosis might have been greater trochanteric bursitis, no right hip pathology was identified in the available studies.

The 13 December 2004 MEB NARSUM examination noted complaints of constant right hip pain with transient tingling.  Right hip ROM was flexion to 90 degrees (normal 125), extension to 10 degrees (normal 20), external rotation to 30 degrees (normal 45), abduction to 12 degrees (normal 45) and adduction to 4 degrees (normal 45); painful motion was present.

At the 25 May 2005 C&P evaluation the CI reported constant right hip pain.  Physical examination showed a normal gait and posture.  Right hip ROM was flexion to 120 degrees, extension to 30 degrees, external rotation to 60 degrees, abduction to 40 degrees and adduction to 20 degrees; pain increased with repetitive movement.

The panel first considered if the right hip condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both the right hip and right knee were considered to fail retention standards, both were implicated by the MEB NARSUM and were profiled.  The commander’s statement referenced the CI’s L3 permanent profile (chronic right hip pain) and specified that the profile limited the CI from performing her radiology technician duties.  Panel members agreed the evidence reasonably justified that the functional limitations of the right hip condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.

As noted above, the PEB bundled the right hip condition with the right knee condition and applied a single 10% rating.  The VA did not service-connect the right hip condition based on the C&P examination, citing a non-compensable examination.  The panel agreed there was insufficient limitation of motion in the right hip to provide a minimum rating using VASRD codes 5251 (thigh, limitation of extension), 5252 (thigh, limitation of flexion) or 5253 (thigh, impairment).  In addition, there was no indication of a flail joint of the hip to support an 80% rating using code 5254, ankylosing of the hip to support a 60% rating using code 5250 or malunion of a femur fracture to support a 10% or higher rating using code 5255.  The panel then considered if painful motion, which was reported on several examinations, justified a minimum rating (based on §4.59, §4.40 and §4.45).  Panel members noted that the application of §4.59 requires the demonstration of joint or periarticular pathology and subjective complaints of pain alone is noncompensable. Having found no identifiable hip pathology or periarticular structures, the panel agreed that a 0% rating was justified.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a separate disability rating of 0% for the right hip condition, analogously coded 5099-5252 (thigh, limitation of flexion).

Right Knee.  According to the STR and the MEB NARSUM, the CI’s right knee pain began in October 2003 associated with increased running requirements.  She was initially treated with medications, activity limiting profiles and a home exercise program with little to no improvement.  An MRI in October 2005 was normal.  The 13 December 2004 MEB NARSUM examination noted complaints of right knee pain.  Right knee ROM was extension to 0 degrees (normal 0) and flexion to 110 degrees (normal 140), with painful motion.

At the 25 May 2005 C&P evaluation the CI reported continued right knee pain and the inability to run, jump or stand for prolonged periods, but denied flare-ups.  Physical examination showed a normal gait and posture.  Right knee ROM was extension of 0 degrees and flexion of 130 degrees, with painful motion.

The panel then considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed the evidence reasonably justified that the functional limitations of the right knee condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  As noted above, the PEB bundled the right hip condition with the right knee condition and applied a single 10% rating.  The VA rated the right knee condition 10%, analogously coded 5099-5003, based on the C&P evaluation 2 months after separation, citing painful motion.

The panel agreed there was no limitation of motion which supported a rating under the diagnostic codes for limitation of 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) as adjudicated by the PEB.  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 a separate disability rating of 10% for the right knee condition, coded 5099-5003.  After reviewing the separate hip and knee ratings, the panel concludes the combined 10% rating does not constitute a rating advantage to the CI and as such, recommends no change in the PEB adjudication for the bundled right knee and right hip condition.

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the bundled chronic pain, right hip and right knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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 20170309, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180005851, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					      
Enclosure