RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01171
BRANCH OF SERVICE:  Army	BOARD DATE:  20140422
SEPARATION DATE:  20020910

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (19K/Abrams Crew Member) medically separated for bilateral patellofemoral pain syndrome.  The CI had a long history of bilateral knee pain, left greater than right and was put on permanent profile when the knee pain began in 1999.  The knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The knee condition, characterized as “bilateral patellofemoral pain, left greater than right,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “bilateral patellofemoral pain syndrome” as unfitting, rated 0%.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 rating for the unfitting knee condition is addressed below; and, 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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20020605	VA – No VA Records in Evidence	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Pain Syndrome	5099-5003	0%					
No Additional MEB/PEB Entries	Other		
Combined:  0%	Combined:  %	

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

The PEB combined the left and right knee patellofemoral pain syndrome conditions under a single disability rating, coded analogously to 5003.  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 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.

Bilateral Patellofemoral Pain Syndrome.  The CI reportedly underwent left knee arthroscopy for meniscal and plica debridement in 1993 and 1994.  A permanent L2 profile was written in 1999 for bilateral knee pain.  In September 2001 he presented with complaints of intermittent left anterior knee pain for nine years.  While the service treatment record (STR) showed multiple visits for left knee pain, there were no visits in evidence for right knee pain.  X-rays of the left knee showed mild degenerative changes.  X-rays of the right knee were not in evidence.

On 24 January 2002 (8 months prior to separation) the CI successfully completed an alternate physical fitness event.  The MEB separation examiner reported that “his left knee still hurts” but was silent about the right knee.  The commander’s statement on 10 April 2002 (5 months prior to separation) reported that his current administrative and supervisory duties were not impacted by his medical condition.

At the narrative summary exam 5 months prior to separation, the chief complaint was “bilateral knee pain, left greater than right.”  The CI reported daily knee pain exacerbated by exertion, and denied any recent history of knee injury.  Examination showed no knee swelling bilaterally.  Range-of-motion was described as “full,” although measurements were 0-135 degrees bilaterally (normal to 140 degrees).  Painful motion of the left knee beyond 100 degrees was noted.  Tenderness of the left lateral patella was also present.  Ligaments were intact.  There was no mention of right knee painful motion or tenderness.

The Board directs attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each knee remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The STR reflected clear, recurring issues with the left knee.  Members agreed that the left knee functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to perform his MOS and, accordingly a separate rating is recommended.  The examination showed minimal, non-compensable limitation of motion.  Board members agreed that a 10% rating is justified IAW VASRD §4.59 (painful motion) based on the service examination findings of pain and tenderness.  The history of persistent symptoms after arthroscopic meniscal debridement also supports a 10% rating under the 5259 code (cartilage, semilunar, removal of, symptomatic).  The Board agreed that there was no route to a rating higher than 10% for the left knee under any applicable VASRD codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition.

Next, the Board turned its attention to the right knee.  As previously elaborated, the Board must first consider whether right knee patellofemoral pain syndrome remains separately unfitting, having de-coupled it from a combined PEB adjudication.  In analyzing the intrinsic impairment for appropriately coding and rating the right knee condition, the Board is left with a questionable basis for arguing that it was indeed independently unfitting.  The well-established principle for fitness determinations is that they are performance-based.  The Board could not find evidence in the STR that documented any significant interference of right knee patellofemoral pain syndrome with the performance of duties at the time of separation, nor were any physical findings documented by the MEB examiner which would logically be associated with significant disability.  It should also be noted that there is insufficient evidence in support of a compensable rating for the right knee condition, even if it were conceded as unfitting.  After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from right knee patellofemoral pain syndrome was integral to the CI’s inability to perform his MOS and, accordingly cannot recommend a separate service 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.  In the matter of the bilateral patellofemoral syndrome condition, the Board unanimously recommends that it be adjudicated for two separate conditions:  In the matter of the left knee patellofemoral pain syndrome condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003.  In the matter of the right knee patellofemoral pain syndrome condition, the Board unanimously agrees that it cannot recommend a finding of unfit for additional service disability rating.  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 Patellofemoral Pain Syndrome	5099-5003	10%	
Right Patellofemoral Pain Syndrome	Not Unfitting	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130826, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

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 XXXXXXXXXXXXXXX, AR20140021525 (PD201301171)

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						     

CF: 
(  ) DoD PDBR
(  ) DVA