RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01196
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020619

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Automation Systems Repairer) medically separated for a bilateral knee condition.  The 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 “bilateral patellar compression syndrome” and “status post arthroscopic surgery for severe patellar maltracking of the left knee” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “bilateral knee pain secondary to retropatellar pain syndrome with chondromalacia status post surgical repair left knee” as unfitting, rated 10% citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He believes he had other medical issues related to his knees.  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 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 20020502	VA* - (~13 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain Secondary To Retropatellar Pain Syndrome…	10%	5099-5003	Left Knee Fulkerson & Lateral Release Surgery Residuals	10%	5257-5010	20030729	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20030904 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  The PEB combined the left and right knee conditions as a single unfitting condition coded analogously to 5003 and rated 10% with application of the USAPDA pain policy AR 635-40 B24.f.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the left and right knee conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Left Knee Condition.  According to service treatment records and the MEB narrative summary (NARSUM), the left knee condition began approximately 4 years prior to referral for MEB.  A left knee X-ray was normal.  An orthopedic surgery consultation documented severe left knee pain along the lateral patellofemoral articulations.  The exam revealed a laterally tilted patella with crepitus (grating sensation or sound).  The assessment listed patellofemoral syndrome ([PFS] symptom complex of anterior knee pain involving the patella) secondary to maltracking.  The CI underwent a left knee arthroscopic procedure (Fulkerson anterior medialization of the patella tibial tubercle at patella insertion) to improve patella tracking.  Serial left knee X-rays showed postoperative changes with a healing tibial osteotomy (surgical procedure where bone is excised or cut to shorten, lengthen, or realign).  Range-of-motion (ROM) was measured with a goniometer by physical therapy (PT) for the MEB.  Bilateral knee active ROM was flexion of 135 degrees (normal 140) and extension of 0 degrees (normal 0).  

The NARSUM dated 21 February 2002 and 4 months before separation, noted that the CI initially complained of left knee pain, followed by right knee pain, with exercise.  He failed conservative management (profile, activity modification, PT, and anti-inflammatory medications) and proceeded to left knee arthroscopy.  The CI reported “much improvement in the pain” after the left knee surgery but declined right knee surgery.  He complained that the left knee still hurt and was unstable.  Bilateral knee pain was exacerbated by prolonged sitting and standing.  The pain was rated as constant and slight and the CI took a nonsteroidal anti-inflammatory drug (NSAID) daily, a combination opioid/analgesic for exacerbations, and used an analgesic cream.  The examiner cited the orthopedic surgery addendum and the PT ROM values.  The diagnoses listed bilateral patellar compression syndrome and status post left knee arthroscopic surgery for severe patellar maltracking.  

The NARSUM addendum by orthopedic surgery on 25 February 2002, documented a history of severe bilateral retropatellar pain syndrome with marked patella lateral tracking.  The left knee arthroscopic exam revealed chondromalacia (abnormal cartilage softening or degeneration) changes and that the corrective surgical procedure improved patella tracking.  Postoperative rehabilitation failed to improve the CI’s quadriceps strength.  He complained of some giving way and lack of stability attributed to his lack of strength.  The physical exam revealed a normal gait.  The left lower extremity exam revealed thigh (3cm) and calf (1.5cm) atrophy.  The surgeon opined that he did not anticipate that the CI had the ability to rehabilitate himself to a level necessary to return to normal military activities.  A subsequent NARSUM addendum on 17 April 2002, documented additional exam findings by the operating orthopedic surgeon.  The left knee exam showed no evidence of instability.  The anterior/posterior drawer (assesses anterior cruciate ligament [ACL]/posterior cruciate ligament [PCL]), Lachman (assesses ACL), and pivot shift (assesses ACL) tests were negative.  

At the VA compensation and pension (C&P) exam performed on 29 July 2003, 13 months after separation, the CI complained of 5 years of bilateral knee pain without specific injury.  He had undergone left knee surgery approximately 2 years prior.  The CI reported he could not run, jump, or walk stairs easily.  He took a NSAID 2-4 times a week with some relief.  The physical exam documented that the CI wore a left knee brace.  The bilateral knee exam revealed no swelling, subluxation, or lateral instability.  The left knee demonstrated slight distal anterior tenderness and the right knee was non-tender.  Bilateral knee ROM was flexion of 140 degrees (normal 140) and extension of 0 degrees (normal 0).  The diagnoses listed status post left knee surgery and right knee sprain.  A right knee X-ray was unremarkable and a left knee X-ray showed postsurgical changes (two screws in proximal tibia), but was otherwise unremarkable.

Right Knee Condition.  While the MEB and PEB implicated bilateral knees, the vast majority of complaints, pathology, imaging, and therapeutic interventions in the STR were related to the left knee.

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each knee condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB rated the bilateral knee condition 10% (coded 5099-5003) citing bilateral knee pain, secondary to retropatellar pain syndrome with chondromalacia, status post surgical repair left knee, and rated as slight/constant pain.  The VA rated the left knee condition 10% (coded 5257-5010) citing the C&P exam 13 months after separation.  The VARD denied service-connection for the right knee because the VA exam found no right knee condition.  For the left knee, the VARD cited surgery residuals, use of a brace, pain, full ROM, pain on motion, tenderness, no swelling, no instability, and no subluxation.  While the MEB and PEB implicated bilateral knees, the vast majority of documented evidence was related to the left knee.  The proximate exams did not demonstrate a limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  Members debated if a 10% ratings was warranted for the bilateral knees with application of VASRD §4.40 (functional loss) or §4.59 (painful motion).  The Board carefully considered the option of rating both knees together, noting that the VA rated only the left knee.  The Board concluded that the evidence did not provide sufficient grounds for recommending separate leg disability ratings in this case, and that a bilateral rating of 10%, coded 5003, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition. 

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 discussed above, PEB reliance on the USAPDA pain policy for rating the bilateral knees was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130903, 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 XXXXXXXXXXXXXXXXXXXX, AR20160000006 (PD201301196)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA