RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01727
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050414

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Chemical, Biological, Radiological, and Nuclear (CBRN) Specialist, medically separated for “chronic bilateral knee pain…” with a disability rating of 10%.  

CI CONTENTION:  The CI contends for his left knee.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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:  

SERVICE PEB - 20050301	VARD - 20051205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain, secondary to Osteoarthritis, Status Post Injury and Surgery	5099-5003	10%	Residuals of Left Knee Medial Meniscus Degeneration	5010	0%	20051011	
			Residuals of Right Knee Medial Meniscus Degeneration	5010	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had right knee reconstructive surgery (patella fracture) as a child and injured his left knee in 2003.  He underwent left knee arthroscopic surgery in October 2003, for medial meniscus and capsule repair for patellar maltracking (dislocating kneecap).  In March 2004 he twisted, fell and injured his right knee.  Despite treatment, the knee conditions could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.  Additional surgery was offered, but reasonably declined and the CI was referred for a Medical Evaluation Board (MEB).  The MEB forwarded “patellar chondromalacia with lateral tracking persisting after corrective surgery in 2003,” “medial meniscus degeneration of the left knee,” “arthritis of the knee, not otherwise specified…,” and “patellofemoral joint pain with lateral maltracking” for PEB adjudication.  

The range of motion (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.  

Knee ROM
(Degrees)	Ortho ~4 Mo. Pre-Sep	PT MEB ~1 Mo. Pre-Sep	VA C&P ~9 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	135	135	132	129	140	140	
Extension (0 Normal)	0	0	3	3	0	0	
Comment:  Left knee surgery 18 Mo. Pre-Sep	Bilateral patellofemoral crepitus; + patellar grind; severe atrophy vastus medialis oblique (VMO) muscle	No painful motion	No painful motion	No painful motion; negative laxity and meniscal testing	No painful motion; negative laxity and meniscal testing	
§4.71a Rating	10%	10%	0%	0%	0%	0%	

An orthopedic appointment on 5 January 2005, 3 months before separation, reported that both knees had positive patella femoral grinding and crepitus.  Both knees had full ROM and had no laxity, instability, tenderness, or deformity aside from well healed scars.  Meniscal testing was negative (McMurray’s and Apley’s) for both knees and there was no VMO muscle atrophy.  The diagnosis was bilateral knee osteoarthritis.  

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 8 February 2005, 2 months prior to separation, the CI reported “extreme arthritis in the knees,” that his knees “dislocated” and that he wore braces on both knees.  Physical examination showed “Lower extremities (Except Feet)” as abnormal.  The examiner’s comments indicated “left knee patellar chondromalacia and lateral tracking disorder” and “left knee medial meniscus tear/degeneration.”  The MEB NARSUM, 9 February 2005, 2 months before separation, noted the CI’s report of “pain in both knees, especially the left;” pain aggravated by walking and climbing up stairs, only relieved by rest and medication; grinding sensations when extending and flexing his knee; and extreme knee pain and numbness with prolonged sitting.  The examiner stated that “knee pain continues to this day making him unable to run, jump, and march or to twist or turn his knee.”  The NARSUM examination documented “patellar crepitus and pain with medial strain of the knee.”  The rest of the physical examination was unremarkable.  Diagnostic imaging (X-ray) in October 2005, 7 months after separation, noted “no fracture, dislocation or other bony, articular or soft tissue abnormality.”  

At the 11 October 2005 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported bilateral knee pain with severe swelling, arthritis and pain that occurred constantly.  He additionally reported four incidents of incapacitation for a total of 45 days over the past year, that he could not run, and that it was difficult to climb stairs.  The condition did not result in any time lost from work.  The CI was taking nonsteroidal anti-inflammatory and narcotic medication.  Physical examination showed a normal gait with well healed scars on both knees.  In addition to full ROM as summarized in the chart above, following repetitive use, the function of the knee joints was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left knee conditions under a single service disability rating, coded 5099-5003, (analogous to degenerative arthritis), rated at 10% citing the US Army Physical Disability Agency pain policy (AR 635-40).  The VA rated the left knee condition 0% coded 5010, (arthritis due to trauma); and the right knee 0% coded 5010, citing normal X-rays and normal ROM in all directions “not limited by pain, fatigue, weakness, or lack of endurance.”  On appeal, the VA changed the left knee rating to 10% coded 5259 (cartilage, semilunar – symptomatic).  

The combined bilateral knee rating 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.  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 did 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 Disability Evaluation System (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.  In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  Each knee was adjudged as reasonably unfitting, and the clinical exams and rating criteria were similar for each knee; although only the left knee had meniscal pathology in addition to patellar chondromalacia and arthritis.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) for either knee.  However, there was evidence of patellar grind, crepitus and pain with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each knee, based on the detailed orthopedic and NARSUM exams.  The VA examination was adjudged as post-separation improvement.  Alternative meniscal rating for the left knee would provide no benefit, and dual rating was not supported for either knee.  After due deliberation, and considering all of the evidence, the Board recommended a disability rating of 10% for the left knee pain condition and 10% for the right knee pain condition, each coded 5099-5014  (chondromalacia; analogous to osteomalacia IAW table of analogous codes).  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the Board unanimously recommends that each joint be separately adjudicated as follows:  an unfitting right knee condition coded 5099-5014 and rated 10%, and an unfitting left knee condition, coded 5099-5014 and rated 10%, both IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Knee Pain	Left	5099-5014	10%	
	Right	5099-5014	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131022, with attachments
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, AR20160008573 (PD201301727)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA