RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX 	CASE:  PD-2013-02661
BRANCH OF SERVICE:  Army	BOARD DATE:  20150804
SEPARATION DATE:  20041112

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (Motor Transport Operator) medically separated for left knee and left hip pain.  The left knee and hip condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “left patellar tendonitis and left trochanteric bursitis existed prior to service (EPTS),” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (hypertension), rated as meeting medical standards, for PEB adjudication.  The Informal PEB adjudicated “left knee (dx’s as patellar tendonitis) and left hip pain (dx’d as trochanteric bursitis)” as unfitting, rated 0%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The hypertension condition was determined to be not unfitting.  The CI made no appeals and was medically separated. 

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:  

IPEB – Dated 2004XXXX	VA* - (~12 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee and Left Hip Pain	5099-5003	0%	Left Knee Tendonitis	5260-5024	10%	20051115	
			Left Hip Strain	5251	10%	20051115	
Hypertension	Not Unfitting 	Hypertension	7101	10%	20051115	
Other x 0 (Not In Scope)	Other x 4	
RATING:  0%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20060621 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:  The PEB combined the left knee and left hip pain under a single Service disability rating, rated 0% and coded analogously to 5003 (degenerative Arthritis,).  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for Service rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  

Left Knee and Left Hip Pain.  The CI was first evaluated for left knee pain in August 2003 during his deployment to Iraq.  He injured his knee after stepping off a vehicle.  The following day he noted sharp pain in his left leg.  His left hip pain soon followed.  He was diagnosed with left iliotibial band (ITB) syndrome and treated with rest, stretching exercises, and insoles.  He returned to the clinic in November 2003 and was prescribed anti-inflammatory and muscle relaxant medication.  The CI underwent consultation with orthopedic in February 2004 and was diagnosed with left trochanteric bursitis and left patellar tendonitis.  He was not a surgical candidate, and thus recommended for MEB.  The commander’s letter dated 22 March 2004 noted that he had felt pressure in his knees after getting out of a truck, and was later diagnosed with bursitis.  The hip condition was not mentioned.  Radiographs of the pelvis, left hip and left knee were normal.  Bone scan of the hips and pelvis was normal.

The narrative summary (NARSUM) was dictated in June 2004; however, the examination was conducted on 23 April 2004.  The CI reported left hip and left knee pain that was worse with sitting than standing.  His knee pain increases with sitting or prolonged standing and decreases with lying down and with ice application.  His hip pain increases with climbing stairs, twisting, and upon awakening, but resolves as the day progresses.  Physical examination documented the use of a cane for ambulation and a gait that was antalgic “in appearance,” opined to be the result of his hip pain.  The left knee demonstrated giveaway weakness with resisted flexion and extension of the knee otherwise the knee exam was normal.  He was unable to perform a deep knee bend due to decreased flexibility and pain in the hip and knee otherwise the hip exam was normal.   Range-of-motion (ROM) recorded for the MEB was performed on 12 May 2005 and documented averages on three trials of left hip flexion at 50 degrees (NL=125), extension of 5 degrees (20), and abduction and adduction at 30 degrees (45).  Left knee ROM recorded an average of 125 degrees (140) of flexion, and normal extension.  The CI’s profile (P3) restricted two mile run,  sit-ups and push-ups, and he could not carry a fighting load; however, could walk at own pace and distance.

The VA Compensation and Pension (C&P) examination performed a year after separation, documented a normal gait, left hip flexion to 80 degrees, abduction to 15 and adduction to 10 degrees, and extension of 0 degrees limited by pain.  He had left knee flexion of 90 limited by pain and DeLuca criteria were absent.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB bundled the hip condition with the knee condition.  The VA, a year after separation, unbundled the conditions and rated the condition of left knee tendonitis, coded analogously 5260-5024, and assigned a 10% evaluation based on painful motion.  The left hip condition was rated under code 5251 ((thigh, limitation of extension) at 10%.  The Board undertook a careful review of the record and concluded the evidence supported the hip condition was separately unfitting, and therefore, proceeded to rate each condition separately.  The Board first undertook the rating of the left knee.  The NARSUM documented a normal knee exam except for an unquantified weakness.  Left leg ROM recordings were slightly reduced but not compensable under any of the ROM codes (5260 and 5261); however, painful motion was documented during ROM testing at the VA, and during the NARSUM exam.  Therefore, Board members agreed the application of VASRD §4.59 was applicable.  There were no other applicable codes to rate the knee.  The Board next proceeded to the rating of the left hip.  The NARSUM documented that the CI had limited ability to perform deep knee bend due to hip pain and lack of flexibility.  Hip ROM demonstrated extension limited to 5 degrees and VA exam documented 0 degrees of extension.  A 10% rating under the 5251 code is assigned when extension is limited to 5 degrees or less.  There were no additional codes to consider. Thereupon, after due deliberation, and careful consideration of all available evidence, the Board unanimously recommends a separation rating of 10% for left knee pain coded analogously 5003, and a rating of 10% for left hip pain coded 5251.  This determination by the Board is IAW VASRD §4.3, §4.59, and §4.71a. 

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the hypertension condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The hypertension condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  This condition was reviewed and considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the hypertension condition and so no additional disability rating is recommended.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the left hip pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5251 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Hip Pain	5099-5003	10%	
Left Knee Pain	   5251	10%	
COMBINED	20%	

The following documentary evidence was considered:

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

XXXXXXXXXXXXXXX 
President 
DoD Physical Disability Board of Review

	SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXXXX, AR20150015579 (PD201302661)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA