RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02771
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070312

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E5, Health Care Specialist, medically separated for “chronic right knee pain” and “chronic left hip pain,” each rated 0%, with a combined disability rating of 0%.  

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 - 20070213	VARD - 20070601	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5099-5003	0%	Residuals, TKR, Right Knee	5055	0%	20070309	
Chronic Left Hip Pain	5099-5003	0%	Left Hip Limitation of Motion and Instability	5010-5251	10%	20070309	
High Frequency Hearing	Not Unfitting	Bilateral Hearing Loss	6100	0%	20070309	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI, while a pedestrian, was hit by an automobile on 6 July 2003.  She subsequently required surgery of both the right knee and left hip.  Despite the surgery, she continued to have difficulty and underwent a total knee replacement (TKR) on 30 April 2004.  She underwent an MEB on 29 June 2004 (not in evidence).  The CI was then activated on 24 August 2004.  She initially did well.  Her activities were limited though due to a pregnancy profile for much of 2005.  She was able to pass a physical fitness test on 12 April 2006 by using a bike as an alternate aerobic event.  Following this event, she had increased pain for which she was evaluated in orthopedics on 5 May 2006.  There she was noted to have a stable knee with painless motion limited to 120 degrees (140 is normal).  At additional orthopedic evaluations over the following 4 months, the examination remained unchanged.  

During the 13 October 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported the use of a knee brace when mountain biking.  The physical examination showed full range of motion (ROM).  The 25 November 2006 MEB orthopedic NARSUM examination, 3 months prior to separation, noted difficulty walking more than a mile with speed and had problems with most field training activities.  The ROM evaluation showed flexion limited to 124 degrees and extension of 2 degrees (normal 0).  Strength and gait were normal.  Instability was not recorded.  The ROM measurements in physical therapy 2 days later showed flexion limited to 135 degrees and hyper-extension of 5 degrees, similar to the unaffected left knee.  

At the 9 March 2007 VA Compensation and Pension (C&P) evaluation, accomplished by a nurse practitioner 6 days before separation, the CI reported that she had been given a waiver for activation as her MOS was critical (manned).  She reported that her knee had been aggravated by physical training and endorsed pain and instability.  On examination, she was could not walk briskly and had a slightly abnormal gait due to the left hip.  Her limitation was minimal though.  The ROM was estimated to be from 5 degrees of hyperextension to 115 degrees of flexion, limited by pain.  The examiner noted that previous X-rays had noted good placement of the prosthesis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined that the right knee condition existed prior to service (EPTS) and without permanent service aggravation.  The CI appealed to the Formal PEB which conceded permanent service aggravation.  The Formal PEB rated the right knee condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA rated the right knee condition 0%, coded 5055 (knee replacement (prosthesis)), based on the C&P examination.  The examiner noted that the CI had a TKR prior to activation and that this supported a 30% rating.  The impairment at separation did not support a 60% rating; hence, the final rating after the EPTS deduction was 0%.  

The panel observed that, under code 5055 (knee replacement), the presence of a knee prosthesis supported a 30% rating at a minimum and that this was clearly present at activation.  In addition, it was determined to be an EPTS condition by the PEB and a 30% deduction, as done by the VA, was determined to be appropriate, but only if the knee replacement were the unfitting condition.  The CI was not found unfit for the knee replacement though, but for chronic right knee pain.  The evidence showed that the CI was able to mountain bike and had a normal gait with full strength on the majority of evaluations.  A compensable rating is not supported under the coding options specific to the knee, but limited and painful motion do support a 10% rating under code 5003.  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 condition, coded 5003.  

Chronic Left Hip Pain.  According to the STR and MEB NARSUM, the CI’s left hip condition began at the time of the right knee injury described above.  Surgery was required for this condition, but it was waived for enlistment.   During the MEB examination, the CI reported persistent occasional pain.  The physical examination revealed a normal gait and ROM.  The MEB NARSUM examination noted complaints of difficulty with sit-ups and field activity.  The physical examination showed, in degrees, flexion of 115 (normal 125), external rotation of 40 (normal 45), and abduction of 50 (normal 45).  Extension was not recorded.  Strength was normal.  Two days later in physical therapy, the values were the same other than abduction of 45 degrees.  Extension was 10 degrees (normal 20).  On 5 February 2007, an X-ray of the pelvis showed an old healed fracture with slight elevation of the right side of the symphysis pubis.  However, this was not seen on a CT scan done 1 hour later.  Mild degenerative changes were present though.  

At the C&P examination, the CI reported pain and instability.  The physical examination showed a slight limp due to the left hip.  The ROM evaluation showed flexion of 115 degrees, extension of 5 degrees, abduction of 25 degrees, and external rotation of 25 degrees.  Motion was limited by pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left hip condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing, the US Army Physical Disability Agency pain policy.  The VA rated the left hip condition 10%, analogously coded 5010-5251 (thigh, limitation of extension of), and based on the C&P examination, citing limitation of extension.  The panel observed that the limitation in motion of the hip to 5 degrees in extension supported a 10% rating.  A 10% rating was also supported for limited, painful motion with X-ray evidence of degenerative changes under code 5003.  This condition was also EPTS, but no objective basis for a deduction was found in the evidence and therefore no deduction is recommended.  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 left hip condition, coded 5003.  

Contended PEB Condition:  High Frequency Hearing Loss.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The condition was not implicated in the commander’s statement or judged to fail retention standards and although the condition was profiled, the examining otolaryngologist recommended return to duty without limitations.  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 matter of the right knee condition, the panel recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the left hip condition, the panel recommends a disability rating of 10%, coded 5251 IAW VASRD §4.71a.  In the matter of the contended high frequency hearing loss, the panel agrees it cannot recommend it for additional disability rating.  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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Knee Pain	5003	10%	
Chronic Left Hip Pain	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170411, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008680, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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