RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD1300648
BRANCH OF SERVICE:  Army	BOARD DATE:  20130924
SEPARATION DATE:  20050613

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (92Y20/Unit Supply Specialist) medically separated for bilateral knee pain.  He injured his right knee when he slipped and fell during basic training; he suffered persistent pain, and ultimately developed left knee pain as well.  Despite right knee surgery, the condition 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 knee condition, characterized as “recurrent bilateral knee pain, therapy resistant,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “chronic bilateral knee pain, right greater than left” as unfitting, rated 10% IAW the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “CHRONIC BILATERAL KNEE PAIN”  

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 Service rating for the unfitting bilateral knee condition is addressed below; no additional conditions are 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 Army Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20050318	VA - (4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain, Right Greater than Left	5099- 5003	10%	Left Knee Condition Status Post Medial Meniscus Tear	5260	10%	20051012	
			Right Knee Condition Status Post Torn Lateral	5260	10%	20051012	
No Additional MEB/PEB Entries	Other x 5	20051008	
Combined:  10%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20060323 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Bilateral Knee Pain.  The CI reported that he had the onset of right knee pain while in basic training.  He was treated conservatively and was able to complete training and function in his MOS although he was seen periodically for pain in the right knee.  However, it did progress and a magnetic resonance imaging (MRI) exam performed in 1998 showed a lateral meniscal tear for which he had arthroscopy with repair of the lateral meniscus and a lateral release (to better align the patella.)  He continued to have pain and was reclassified to his current MOS after a Medical MOS Retention Board.  He was noted to have left knee pain as well at the 21 June 2000 orthopedic appointment.  The CI also apparently had an MRI of the left knee which showed a medial meniscus tear.  This record is not in evidence.  He was issued a L3 profile for bilateral knee pain and referred to MEB.  The commander’s letter was dated 9 December 2004 and annotated that he is unable to perform his duties secondary to right knee pain.  The narrative summary (NARSUM) was dictated on 8 February 2005, 4 months prior to separation, and noted that the CI walked with an antalgic gait secondary to left knee pain.  He had full range-of-motion (ROM) of both knees without signs of instability, meniscal irritation or effusion.  However, there was a positive patellar apprehension consistent with retro-patellar pain syndrome (RPPS), a diagnosis he carried in the medical records.  There was no muscle atrophy and the neurological examination was normal.  A recent MRI of the right knee was essentially negative.  There were degenerative changes noted on bilateral knee X-rays.  The CI was noted to have bilateral knee pain resistant to therapy which was not amendable to surgical correction.  This was thought to be incompatible with further military service.  At the VA Compensation and Pension (C&P) examination performed 4 months after separation, the CI reported that the bilateral knee pain was aggravated by squatting, kneeling and throwing.  There was no evidence of swelling, weakness, giving away or locking.  He did not use an assistive device, but walking was limited to half mile secondary to pain.  On examination, the knees had normal ROM without effusion or crepitus.  Testing for instability was negative as were provocative tests for meniscal irritation.  The patellar apprehension test was again positive.  On repetitive testing, the CI endorsed fatigue and lack of endurance, but denied an increase in pain.  The Board observed that the examiner did not specify that the ROM was painful though.  The gait was normal.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

DOS 20050613
Knee ROM
(Degrees)	PT ~ 8 Mo. Pre-Sep	MEB ~ 4 Mo. Pre-Sep	VA C&P ~ 4 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	FROM	115-120	FROM 	FROM	140	140	
Extension (0 Normal)	FROM	-5	FROM	FROM	0	0	
Comment	Bilateral + patellar grind	Bilateral + patellar grind; antalgic gait 	DeLuca positive for decreased endurance and fatigue, but w/o increased pain	
§4.71a Rating	0%	10%	0%	0%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB bundled the knees together and rated them at 10% using the 5003 code, degenerative arthritis.  The VA coded and rated each knee separately using the 5260 code, limitation in flexion, and rated each at 10%.  The Board first considered if the knees were separately unfitting noting that the PEB bundled them together.  There was evidence of degenerative changes on X-rays of both knees and, by report in the C&P, evidence of meniscal tears bilaterally on MRI.  The profile was for bilateral knee pain, although the commander noted that the CI was limited secondary to pain in his right knee.  The NARSUM examiner attributed the antalgic gait to the left knee.  The Board determined that the preponderance of evidence supported a finding of each knee being separately unfitting.  The Board then considered the appropriate coding and rating for each knee.  It noted that each knee had degenerative changes on X-ray and evidence of a meniscal tear on MRI, although the left knee report is not in the record and was found in the VA C&P.  The Board considered the available coding options for the knees and determined that the 5259 code, cartilage, semilunar, removal of, symptomatic best fit the disability.  The CI had positive DeLuca findings for both knees on the VA C&P examination, an abnormal gait secondary to left knee pain on the NARSUM examination and was noted by his commander to have duty restrictions secondary to right knee pain.  The Board determined that this met the disability description for a 10% rating bilaterally.  

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 bilateral knee pain condition, the Board unanimously recommends a disability rating of 10+10%, coded 5259 and 5299-5259, right and left, 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:  

UNFITTING CONDITION	VASRD CODE	RATING	
Left Knee Condition	5299-5259	10%	
Right Knee Condition 	5259	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130522, 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 /XXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXXXX, AR20130021812 (PD201300648)

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