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AF | PDBR | CY2012 | PD2012 01880
Original file (PD2012 01880.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201880
BRANCH OF SERVICE: Army  BOARD DATE: 20130627
SEPARATION DATE: 20031216


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92Y10/Unit Supply Specialist) medically separated for osteoarthritis of the bilateral knees, low back, hips and left shoulder. The pain developed insidiously in 2002, with no inciting trauma. The CI could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded “osteoarthritis of the bilateral knees, lower back, hip and left shoulder” to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “osteoarthritis bilateral knees, low back, hips and left shoulder with incapacitating episodes” as unfitting and rated 0%. The CI made no appeals and was medically separated.


CI CONTENTION: “My Record didn’t reflect my true Diagnosis because mission first Led me do not worry about medical. My PTSD LED me to this wrong.”


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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The ratings for the unfitting osteoarthritis bilateral knees, low back, hips and left shoulder conditions are addressed below. The requested posttraumatic stress disorder condition was not identified by the PEB, and thus is not within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.


RATING COMPARISON:

Service IPEB – Dated 20031114
 VA - (2 weeks Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Osteoarthritis Bilateral Knees, Low Back, Hips and L/Shoulder with Incapacitating Episodes of Pain but No X-Ray Evidence or Loss of Joint Motion
 5003 0% Chondromalacia Patellae L/ Knee 5299-5260 10% 20031201
Chondromalacia Patellae R / Knee 5299-5260 10% 20031201
Residuals of Low Back Sprain 5299-5237 10% 20031201
Adductor Tendonitis, Right Hip 5315-5252 10% 20031201
Left Shoulder Sprain 5299-5203 10% 20031201
No Additional MEB/PEB Entries
 Other x 10 20031201
Combined: 0%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 40126 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY: The PEB combined the osteoarthritis bilateral knees, low back, hips, and left shoulder conditions under a single disability rating, coded 5003 (arthritis, degenerative [hypertrophic or osteoarthritis]). Although the Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints. IAW DoDI 6040.44 the Board must follow suit 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 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. To that end, the evidence for the bilateral knees, left hip, low back, and left shoulder conditions are presented separately with attendant recommendations regarding separate unfitness and separate rating as indicated. The right-handed CI was given a permanent lower extremity (L3) profile on 9 September 2003 for bilateral knee pain (retropatellar) and adenitis of the right hip. The CI was profiled from all functional activities. His commander’s statement remarked that the CI had been working in his primary MOS (PMOS) since July 2001, and executed his duties admirably. His profile, however, prevented the CI from running, jumping, walking, lifting, and field duty; the CI could not participate in physical training, go to the field or deploy with the battery, or lift anything to put on the supply shelves, a part of his duty in his PMOS.

Bilateral Knees. The first entry in the service treatment record (STR) for the knees was an emergency room visit with a 3 week history of right greater than left knee pain with application of pressure on 6 September 2001; 7 months after entry into active duty, he had tender knees and normal X-rays. He was treated with non-steroidal anti-inflammatory medication and physical therapy. Orthopedics evaluated the CI on 15 October 2001 for right knee retropatellar pain syndrome. He was additionally diagnosed and treated for bilateral iliotibial band syndrome after an injury playing soccer on 26 November 2001. On 30 September 2002, a note from the chief of orthopedics/rehabilitation addressed the right knee and issued a P2 profile for that condition. A year later on 9 September 2003, the CI was given a permanent lower extremity profile L3 for bilateral knee pain and right hip adenitis. The profile restricted aerobic conditioning exercises to only at own pace as well as all functional activities, physical fitness tests, no running, no jumping, no rucksack marching, no lifting, no field duty, and no alternate Army Physical fitness Test (APFT). On the MEB narrative summary, dated 30 October 2003 (2 months prior to separation) the CI stated he had a year history of bilateral knee pain, which developed insidiously without inciting trauma. The knee pain was reported 5 out of 10, constant, and worse with sitting for long periods, running, jumping, ruck sacking, crawling, up or down stairs, and cold weather. Physical examination revealed a 2A Lachman’s test (0.5-1.0 cm of translation), stable to varus and valgus stress bilaterally. He had pain with manipulation of both patellae and tibial tendons, as well as pain with resisted motion of the quadriceps tendon; there was no pain with full ranges of motion of the knees. He was unable to perform his duties of lifting and carrying 100 pounds at times, and recurrent incapacity for prolonged periods. On the VA Compensation and Pension examination, 1 December 2003 (3 weeks prior to separation) the CI reported daily bilateral knee pain since 2002, maximum 10 out of 10, worse with squatting, kneeling, or running, and improved with ice and massage. The physical examination revealed a left antalgic gait due to back pain with bilaterally normal ligamentous stability, 3+ crepitus, tenderness of the patellae, and ranges-of-motion (ROM) measured at 0-140 degrees (normal) bilaterally. Right and left knee X-rays were interpreted as within normal limits.

The Board directs attention to its rating based on the above evidence. The Board first considered if the bilateral knee condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. Members agreed that the functional limitations in evidence justified the conclusion that the knee condition was integral to the CI’s inability to perform his MOS rating and, accordingly, that a separate rating is recommended. The evidence makes clear that the right knee was associated with more disability than the left one in this case. The disparity was such that the question was raised of whether the left knee was reasonably justified as separately unfitting. The Board agreed that evidence in the treatment record would suggest the left knee did not rise to the level of being separately unfitting and therefore cannot recommend a separate rating for it. The Board considered VASRD diagnostic code 5003 (degenerative arthritis) used by the PEB for a 0% adjudication. Members agreed that the persistent functional limitations in evidence were difficult to reconcile with a 0% rating, and that VASRD §4.40 (Functional loss) was supported to achieve the minimum rating of 10%. §4.40 states, “a part which becomes painful on use must be regarded as seriously disabled,” and there is ample evidence in the form of evaluations and profiles that such was the case with the right knee pain condition. The Board considered codes 5299 (rated analogous to) 5260 (limitation of flexion of leg) used by the VA for a 10% rating. There was no degree of ROM limitation, instability, locking, effusion, radiographic abnormalities, or painful motion, which would achieve a compensable rating, thus barring application of §4.40 (Functional loss) to achieve the minimum compensable rating of 10% under the available VASRD knee codes. The Board could not find evidence in the treatment record of recurrent incapacitation for any period from the CI’s duties that would require rest, medical attention, or absence from work. After due deliberation and with deference to VASRD §4.3 (Reasonable doubt), members agreed that the right knee condition, IAW VASRD §4.71a rating criteria and accepted principles for fitness determination, warrants recommendation for a rating of 10% under VASRD codes 5099 (rated analogous to) - 5003 (degenerative arthritis).

Right Hip. There is little evidence in the STR of any treatment or evaluation for hip pain, only two normal radiographic studies on 11 August 2003 and 5 September 2003. There is mention on the permanent L3 profile for bilateral knee pain and adenitis of the right hip on 9 September 2003. The commander’s statement does not specifically mention the hip as duty-limiting. The Board first considered whether the right hip condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. Members agreed that, based on the above evidence, there was a questionable basis for this condition being separately unfit. The well-established principle for fitness determinations is that they are performance-based. The Board could not find evidence in the commander’s statement or elsewhere in the STR that documented any significant interference of right hip condition with the performance of duties at the time of separation, nor were any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability above those already imposed by the right knee condition. Additionally, the CI passed his 27 July 2003 alternate APFT with a 2.5 mile walk. After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from the right hip condition was integral to the CI’s inability to perform within his MOS and accordingly cannot recommend a separate rating for it.

Lower Back. The first evidence in the record of low back pain (LBP) from a 2 May 2002 troop clinic visit for a 2-month history of LBP without trauma. Physical exam was unremarkable and a normal X-ray. On 6 July 2003, there was an emergency room visit for LBP for a day. X-ray was performed and reported as normal. He was treated with physical therapy in July and August 2002. The condition was not profiled and not mentioned in the commander’s statement. The Board first considered whether the LBP condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. Members agreed that, based on the above evidence, there was a questionable basis for this condition reasonably being considered separately unfitting. The Board could not find evidence in the commander’s statement or elsewhere in the STR that documented any significant interference of the LBP condition with the performance of duties at the time of separation, nor were any physical findings documented by the MEB or VA examiners that would be interpreted as indicating significant disability. After due deliberation members agreed that the evidence does not support a conclusion that the functional impairment from LBP was integral to the CI’s inability to perform his MOS duties; accordingly the Board cannot recommend a separate rating for it.

Left Shoulder. The Board did not find evidence of diagnosis or treatment for the left shoulder pain in the STR. The Board first considered whether the left shoulder pain condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. Members agreed that, based on the evidence, there was a questionable basis for considering it as separately unfitting. The Board could not find evidence in the commander’s statement or elsewhere in the STR that documented any significant interference of the left shoulder pain with the performance of duties at the time of separation, nor were any physical findings documented by the MEB or VA examiners that would be interpreted as indicating a significant disability. After due deliberation members agreed that the evidence does not support a conclusion that the functional impairment from the left shoulder pain was integral to the CI’s inability to perform his MOS duties; accordingly the Board cannot recommend a separate rating for it.


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 knee pain condition, the Board unanimously recommends a disability rating of 10% right knee, coded 5099-5003 IAW VASRD §4.71a. In the matter of the left knee, left hip pain, LBP, and left shoulder pain conditions, the Board unanimously agrees that it cannot recommend additional disability ratings.


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

UNFITTING CONDITION
 VASRD CODE RATING
Right Knee Pain
5099- 5003 1 0%
Left Knee Pain
 Not Unfitting
Right Hip Pain
 Not Unfitting
Low Back Pain
 Not Unfitting
Left Shoulder Pain
 Not Unfitting
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20121010, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130019768 (PD201201880)
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 10% 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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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