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AF | PDBR | CY2013 | PD-2013-01337

Original file (PD-2013-01337.rtf) Auto-classification: Approved

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX CASE: PD-2013-01337
BRANCH OF SERVICE: Army BOARD DATE: 20150605

SEPARATION DATE: 20010916

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Unit Supply Specialist) medically separated for left hip and bilateral knee pain. The CI’s joint pain could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS). She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The left hip and bilateral knee pain conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. There were no other conditions. The Informal PEB combined the left hip and bilateral knee pain into a single unfitting condition, rated 0%, c iting application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals at that time, and was medically separated.

CI CONTENTION: The CI contends that her hip and knees continue to bother her.

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 Veterans Affairs Schedule for Rating Disabilities (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 20010521	VA* - (~3 mos. Post-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Left Hip and Bilateral Knee pain	5099-5003	0%	Residuals, Left Hip Stress Fracture	5099-5010	10%	20011212
			Right Knee Chondromalacia	5099-5010	10%	20011212
			Left Knee Chondromalacia	5099-5010	10%	20011212
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2
RATING: 0%	RATING: 30%

* Derived from VA Rating Decision (VA RD ) dated 200 20708 (most proximate to date of separation ( DOS ) )

ANALYSIS SUMMARY:

Left Hip and Bilateral Knee Pain. This CI entered the Army in May 1999. A few months later, in September 1999, while in Advanced Individualized Training (AIT), she developed pain in the left hip and groin region. On 25 October 1999, a bone scan showed stress fracture of the left femoral neck. She was treated with crutches, physical therapy (PT) and other conservative measures. When an attempt was made to discontinue crutches and gradually increase her activity level, her hip pain got worse. On 18 May 2000, magnetic resonance imaging (MRI) of the left hip was unremarkable. On 24 August 2000, a repeat MRI of the left hip was done and it also was unremarkable. In September 2000, a year after the onset of hip pain, the CI developed bilateral knee pain, left greater than right. She was evaluated by PT, and was diagnosed with Retropatellar pain syndrome (RPPS). On 17 October 2000, her knees were examined by an orthopedist. There was no erythema (redness), edema (swelling), or laxity. Both knees had full range-of-motion (ROM). The examiner’s diagnostic assessment for the knees was: Bilateral knee pain, possibly due to chondromalacia.

Because of the chronic, persistent nature of her joint pain, an MEB was initiated. The MEB narrative summary (NARSUM) was dated 8 March 2002. The CI reported that her pain prevented her from prolonged standing or walking, and she was unable to perform the duties of her MOS. She walked with a slightly antalgic gait. On physical examination (PE) of her left hip and groin region, there was diffuse tenderness to palpation (TTP) over several areas. Knee exam revealed mild patellofemoral crepitus bilaterally. The ROM of her left hip and knees was measured, and is summarized in the charts below.

The CI was medically separated from service on 16 September 2001. On 19 December 2001, 3 months later, she had a VA Compensation and Pension (C&P) exam. She reported that she could not walk long distances, nor could she tolerate long sitting. She was taking Aleve (naproxen) daily, to alleviate her pain. On PE of the left hip, there was some mild swelling and tenderness noted. PE of her right knee revealed minimal evidence of effusion. There was mild peri-patellar tenderness, but no joint line tenderness. The patella tracked well, and there was some crepitus noted. All tests for ligamentous laxity were negative. Quadriceps strength was normal, and the right leg was neurovascularly intact. PE of the left knee revealed no evidence of effusion. There was mild peri-patellar tenderness, but no joint line tenderness. There was some crepitus noted. All tests for ligamentous laxity were negative, and the left leg was neurovascularly intact. The ROM of left hip and knees was measured, and is summarized in the charts below.

Left Hip (Thigh) ROM (Degrees)	MEB ~ 6 mos . Pre-Sep (200 10308 )	VA C&P ~ 3 mos . Post- Sep (200 1121 9 )
Flexion (125 Normal)	95-100	85
Extension	10	5
External Rotation	20-25	35
Abduction ( 45)	25-30	(not recorded)
Comment	(approximations)	p ainful motion *

invalid font number 31502 invalid font number 31502 *10% rating IAW VASRD §4.40 (Functional loss), §4.45 (The joints), and §4.59 (Painful motion)

Knee ROM (Degrees)	MEB ~ 6 mos . Pre-Sep (200 10308 )	VA C&P ~ 3 mos . Post-Sep (200 11219 )
		Left	Right	Left	Right
Flexion (140 Normal)		>125	>125	1 15	1 25
Extension (0 Normal)		0	0	-5	0

As noted above, t he PEB combined the CI’s hip pain with the knee pain , into a single unfitting condition : “ Left hip and bilateral knee pain, with history of a now healed left hip stress fracture .” The unfitting condition was coded 50 99-5003 a nd rated at 0%. In contrast, the VA rated each joint (left hip, left knee, and right knee) separately. The Board evaluated whether or not it was appropriate for all the joint pain problems to be “bundled” together. The Board must determine if the PEB’s approach of combining the conditions under a single rating was reasonably justified in lieu of separate ratings. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each invalid font number 31506 condition are achieved IAW the V ASRD §4.71a. If the Board judges that two or more separate ratings are warranted, however, it must satisfy the requirement that each ‘unbundled’ condition was separately unfitting. A fter due deliberation, the Board agreed that the evidence in the record does not support a conclusion , that the left hip pain , and the bilateral knee pain , separately, would have rendered the CI unable to perform h er required military duties. Specifically, the Board found insufficient evidence that the knee pain condition was separately unfitting. The bilateral knee pain condition, separately, would not have rendered the CI unable to perform h er required military duties. Accordingly, the Board does not recommend a separate Service disability rating for left hip pain, and for bilateral knee pain . It is appropriate for the joint pain problems to be bundled together, and treated as a single unfitting condition .

The Board directed attention to its rating recommendation based on the evidence. The Board determined that the painful joint condition was essentially non-compensable based solely on the VASRD §4.71a codes for loss of joint motion. However; IAW VASRD §4.40, §4.45, and §4.59, when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled. A 10% rating is warranted when there is satisfactory evidence of functional limitation due to painful joint motion. There was no path to a higher rating there was insufficient evidence of a seriously disabling bone or joint abnormality that would justify a higher rating. After due deliberation, the Board determined that a disability rating of 10% was appropriate. Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends a 10% disability rating for the chronic unfitting left hip pain, and bilateral knee pain.

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. As noted above, PEB reliance on the USAPDA pain policy was operant in this case. The CI’s unfitting condition was adjudicated independently of that policy by this Board.

In the matter of the Left hip and bilateral knee pain, the Board unanimously recommends a disability rating of 10%, coded 5099-5003, IAW VASRD §4.40, §4.45, §4.59, and §4.71a.

There were no other conditions within the Board’s scope of review for consideration.

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

CONDITION	VASRD CODE	RATING
Left hip and bilateral knee pain	5099-5003	10%
COMBINED	10%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130208, w/atchs
Exhibit B. Service Treatment Record

Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
President
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 AR20150012421 (PD201301337)

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              XXXXXXXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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AF | PDBR | CY2013 | PD-2013-01337

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