RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1301479
BRANCH OF SERVICE:  Army	BOARD DATE:  20140423
SEPARATION DATE:  20061124

SUMMARY OF CASE:  The available evidence indicates this covered individual (CI) was an active duty PFC/E-4 (63B/Light Wheeled Vehicle Mechanic) medically separated for a bilateral knee condition.  This condition could not be rehabilitated, so he was referred for a Medical Evaluation Board (MEB), which forwarded “bilateral retro-patellar pain syndrome” (RPPS) as not meeting retention standards to the Physical Evaluation Board (PEB) IAW AR 40-501.  Two other conditions, adjustment disorder and left cubital tunnel syndrome, were also forwarded to the PEB as meeting retention standards.  The Informal PEB adjudicated “bilateral knee pain with atraumatic onset” as unfitting, rated 0%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy; the remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “For this and other conditions the VA already rate.  I have been unemployed since 2006.” 

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 applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20060928	VA - (1 Mos. /Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	RPPS, Right Knee	5260	0%	20061230	
			RPPR, Left Knee	5260	0%	20061230	
Adjustment d/o w/ Depression,  Anxious Mood	Not Unfitting	Adjustment d/o w/Mixed Features	9440	10%	20061221	
Left Cubital Tunnel Syndrome	Not Unfitting	Left Hand CTS; Left Ulnar Elbow Neuropathy	8515	10%	20061230	
No Additional MEB/PEB Entries	Other x 1, NSC x 3	20061230	
Combined:  0%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20070726.

ANALYSIS SUMMARY:

Bilateral Knee Condition. The record first shows the CI evaluated for bilateral knee pain on 24 August 2005 when he was diagnosed with bilateral RPPS; pain behind the knee cap and treated conservatively.  He was next seen on 11 January 2006 and noted left knee pain after running but denied trauma.  The CI was thought to have a possible lateral meniscal tear (the outside meniscus which is a cartilage cushion between the bones of the knee), though a magnetic resonance imaging (MRI) exam on 3 March 2006 was normal.  X-rays of both knees on 28 April 2006 were also normal.  X-rays of both knees were taken again on 17 May 2006 and mild medial (inside) compartment narrowing was noted, but these were normal otherwise.  He was seen in orthopedics that day and it was noted that he had been on a profile for 6 months for his knees.  The CI reported his right knee became symptomatic in October 2005 and his left in January 2006.  He had failed conservative treatment including physical therapy, duty limitations and medications.  On examination, he wore a neoprene sleeve and had an abnormal gait (protected walking to avoid pain).  The CI’s strength was normal but he had trouble with heel to toe walking.  The range-of-motion (ROM) of both knees was normal and the knees were stable and without effusion, but pressure over the kneecap (patella) was painful bilaterally.  The orthopedist noted that the X-rays were normal and the CI was diagnosed with bilateral RPPS.  At the MEB examination on 2 June 2006 the CI reported bilateral knee pain.  The MEB physical examiner also noted normal ROM, stable knees, and painful patellar compression.  The narrative summary dated 20 July 2006 noted that the CI reported his left knee became symptomatic when an engine starter fell on it in October 2005.  The examiner noted the CI had failed conservative treatment.  The CI stated he had constant pain in his knees that was aggravated by activity, though painful motion was not documented.  The examiner referred to the 17 May 2006 orthopedic examination but did not perform a separate examination that day.  It was determined that the bilateral RPPS failed retention standards.  At the VA Compensation and Pension (C&P) joint examination performed on 23 December 2006 (a month after separation) the CI reported continued pain, but neither locking nor giving way was recorded.  On examination, ROM was limited to 130 degrees in flexion bilaterally (with pain at the end of flexion) and normal extension; the examiner did not specifically note the reason for the limitation in motion.  The knee was stable to examination and the CI walked with a slight limp.  He was thought to have bilateral patello-femoral pain syndrome and a plica (redundant fold of the joint lining) on the left.  X-rays were negative.  A week later, a general C&P examination was conducted.  Swelling of the left knee was documented, but no effusion (fluid in the joint) was recorded.  ROM was recorded as 125 degrees of flexion bilaterally, limited by pain at 180 degrees (the inconsistency was noted by this board).  Gait was documented as normal.  The CI was also evaluated for chronic low back pain by the VA.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the bilateral knee pain as 5099-5003, analogous to degenerative arthritis and the VA 5260, limitation in flexion, but both rated the knees at 0%.  The Board noted the ROM was normal at the military examinations and slightly reduced at the VA examinations, but not to a compensable degree.  There was no sign of instability, effusion or a meniscal problem (a possible meniscal tear of the left was excluded on MRI.)  Painful motion was not clearly documented to support the use of VASRD §4.59.  (An antalgic gait was sometimes documented, but normal at other visits and it was not distinguished whether the knees or the back caused the abnormal gait it was recorded).  The Board considered the coding options available for the knee and found no route to a rating higher than the 0% rating adjudicated by both the PEB and VA.  The Board observed that while each knee could be adjudicated as separately unfitting, this provides no advantage to the CI.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee pain condition.

Contended PEB Conditions.  The CI also contended for the left CTS and adjustment disorder conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that these were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Left CTS (nerve impingement at the inside of the elbow) was noted by the examining neurologist on 27 June 2006 to impair duty.  The examiner also recorded, though, that the CI had not had an adequate treatment trial and that full recovery was anticipated, so the left CTS was determined to meet retention standards at this examination.  It was thought the CTS would most likely recur if he were to return to his occupation as a mechanic.  The commander noted this condition impaired duty performance; the condition was given a temporary U3 profile on 22 August 2006, but the final profile (dated 12 September 2006) was U1.  The MEB determined this condition met retention standards and the PEB adjudicated it as not unfitting.  The Board observed that, absent the bilateral unfitting knee condition, recommending cross training would have been an option for the PEB.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended left CTS condition, so no additional disability rating is recommended.

The adjustment disorder was evaluated as a result of the CI annotating MH complaints during the MEB process secondary to input from his spouse; he was determined to meet retention standards by the examining psychiatrist and to have no military or occupational impairment due to a MH condition.  The Panel first considered the diagnosis and noted the CI was diagnosed with an adjustment disorder both while in the Disability Evaluation System (DES) and by the VA and that this diagnosis did not change in the DES process.  This applicant therefore did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The adjustment disorder was neither profiled nor implicated by the commander.  The MEB found it to meet retention standards.  There was no performance based evidence in the record that the adjustment disorder or any other MH condition significantly interfered with satisfactory duty performance; nor was there any basis for consideration of an alternative MH diagnosis.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended adjustment disorder, so no additional disability rating is recommended.

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 described above, PEB reliance on the USAPDA pain policy for rating the bilateral knee condition was likely operant in this case; the condition was considered independently of that policy by the Board for this recommendation.  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left CTS and adjustment disorder conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130918, 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 XXXXXXXXXXXXXXXXXX, AR20140013578 (PD201301479)

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