RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01299
BRANCH OF SERVICE:  Army	BOARD DATE:  20141002
Separation Date:  20040731

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (52D/Power Generation Equipment Repairer) medically separated for chronic bilateral knee pain.  The knee 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 “severe bilateral knee pain with mild diffuse cartilage loss in the medial compartment consistent w/chondromalacia,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “chronic bilateral knee pain due to chondromalacia” as unfitting, rated 20% citing the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI writes: “20% SC instead 60% SC.”

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 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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20040524	VA - (8 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain due to Chondromalacia	5099-5003	20%	Chondromalacia Patella L Knee	5261	20%	20050311	
			Chondromalacia Patella, R Knee	5261	20%	20050311	
Other X 0 (Not in Scope)	Other x 0	20050314	
Combined:  20%	Combined:  40%	

Derived from VA Rating Decision (VARD) dated 20050412 (most proximate to date of separation [DOS])

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

The PEB rated the chronic bilateral knee pain due to chondromalacia condition under the single analogous code of 5099-5003 (degenerative arthritis).  This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation.  The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each joint are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as unfitting in and of itself, with the caveat that the final recommendation may not produce a lower combined rating as that of the PEB.

Chronic Bilateral Knee Pain due to Chondromalacia Condition.  The CI developed bilateral knee pain during boot camp in April 2002 and was treated with a non-steroidal anti-inflammatory drug (NSAID).  The pain worsened and he started to have bilateral knee swelling.  He was seen by Family Practice for bilateral knee pain, swelling, crepitus and painful motion.  The examiner diagnosed retropatellar pain syndrome and prescribed a 3 month profile, physical therapy consult, NSAID, X-ray and ice massage.  The CI reinjured his left knee and the X-ray showed a small effusion.  The CI continued to be followed by Family Practice and was noted to have chronic bilateral knee pain, mild abnormal patella tracking, pain and edema.  The left and right knee magnetic resonance imaging (MRI) demonstrated mild diffuse cartilage loss in the medial knee without meniscal or ligament tears.  The orthopedist noted bilateral knee pain left worse than right, increased pain, swelling and an antalgic gait with locking, catching, edema and instability.  The physical exam findings were mild tenderness to palpation at the medial joint lines, positive McMurray’s sign along the medial joint line and retropatellar crepitus.  The CI was given a permanent L3 Profile for severe knee pain with cartilage loss in both knees.  The MEB narrative summary (NARSUM) exam approximately 3.5 months prior to separation documented that the CI had sharp, constant bilateral knee pain and swelling which was worse with walking, lifting objects or carrying heavy objects.  He had bilateral knee popping when walking and occasionally walked with a limp.  The examiner rated the pain according to the American Medical Association pain scale at slight to moderate and constant.  The MEB NARSUM physical exam findings are summarized in the chart below.  The commander’s statement indicated that the CI’s condition prevented him from performing the duties of his MOS.  

The VA Compensation and Pension (C&P) exam approximately 7.5 months after separation documented worsening of the bilateral knee pain which was precipitated by walking and standing a lot and the CI required a cane for ambulation outside of the house.  The VA C&P physical exam findings are also summarized in the chart below.

There were two goniometric range-of-motion evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the following chart:

Knee ROM (Degrees)	NARSUM 3 Mos. Pre-Sep	VA C&P 7 Mos. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	115	115 (116)	110	110	
Extension (0 Normal)	0	0	-10	-10	
Comment	Pos. painful motion, crepitus and effusions; Pos. tenderness to palpation; No instability; Normal strength	Normal gait; Pos. painful motion & crepitus; No instability, weakness, or effusion; Pos. DeLuca criteria	
§4.71a Rating	10%	10%	20%	20%	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the chronic bilateral knee pain due to chondromalacia condition as 5099 analogous to 5003 (degenerative arthritis) and rated at 20% with application of the USAPDA pain policy.  The VA coded the chondromalacia patella with patellofemoral pain syndrome, left knee and right knee separately as 5261 (limitation of leg extension) and rated at 20% each knee, including 10% added to each knee citing DeLuca criteria.  All exams accomplished proximate to separation documented pain limited motion for both knees.  There was no distinction in the record that one knee was worse than the other, both knees had similar MRI finding of mild diffuse cartilage loss in the medial compartment without meniscal or ligament tears and there were no unilateral distinctions with regards to clinical features or fitness considerations.  Board members agree that there are sufficient grounds for recommending separate right and left knee disability ratings at the time of separation.  The chronic bilateral knee pain due to chondromalacia condition was most compatible with VASRD code 5099-5003 as applied by the PEB.  The Board adjudged that the MEB examination was closer to separation and therefore had the higher probative value.  Application of VASRD §4.59 (painful motion) and §4.40 (functional loss) is appropriate based on the evidence and under code 5003 is granted a 10% rating for each knee.  The Board considered the 20% for each knee as granted by the VA, however, the Board placed greater probative value on the more proximate, pre-separation data contained in the NARSUM.  There was no evidence of incapacitation due to the knee pain as required for a 20% rating under code 5003.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee pain condition coded 5099-5003 and rated 10%, and an unfitting left knee pain condition, coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  Although the PEB cited the USAPDA pain policy to arrive at its 20% rating, the Board’s rating recommendation of 10% for each knee also results in a 20% combined rating and confers no benefit to the CI.

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 (635-40) for rating the chronic bilateral knee pain due to chondromalacia condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic bilateral knee pain due to chondromalacia condition and IAW VASRD §4.71a, and although it confers no benefit to the CI, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee pain condition coded 5099-5003 and rated 10%, and an unfitting left knee pain condition, coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  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 20130909, 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 XXXXXXXXXXXXXXXXX, AR20150002678 (PD201301299)

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:

Encl						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA