RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01833
BRANCH OF SERVICE:  Army	BOARD DATE:  20141118
DATE OF PLACEMENT ON TDRL:  20040807
Date of Permanent SEPARATION:  20050614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (91G/Patient Administration Specialist) medically separated for Crohn’s disease and knee pain.  The Crohn’s disease and left 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 P3/L3 profile and referred for a Medical Evaluation Board (MEB).  “Crohn’s disease, uncontrolled” and “left knee retropatellar pain syndrome status post arthroscopy with synovectomy,” conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “Crohn’s disease” and “chronic left knee pain” as unfitting, rated at 30% and 10% respectively, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI did not appeal and was placed on the Temporary Disability Retirement List (TDRL).  Ten months later, the TDRL PEB readjudicated the Crohn’s disease as unfitting, rated at 10% with application of the VASRD; and bilateral knee pain as unfitting, rated at 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was permanently 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 ratings for the unfitting Crohn’s disease and bilateral knee condition are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any condition 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.

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 VASRD standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Final Service PEB - 20050608	VA (4 Mo. Prior to TDRL Placement) - Effective 20040807	
On TDRL - 20040807	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
Crohn’s Disease	7399-7323	30%	10%	Crohn’s Disease	7399-7323	30%	20040329	
Left Knee	5099-5003	10%	--	Left Knee	5260	10%	20040329	
Bilateral Knee Pain	5099-5003	--	0%	Right Knee	5260	10%	20040329	
Other x 0 (Not in Scope)	Other x 4	
Combined:  40% → 10%	Combined: 50%	

ANALYSIS SUMMARY:

Crohn’s Disease.  In 1996 the CI was diagnosed with Crohn’s disease after undergoing a diagnostic colonoscopy.  Despite anti-inflammatory pain medication, his symptoms of intermittent abdominal pain, frequent diarrhea with rectal bleeding continued.  He developed a chronic anal fistula (an abnormally formed tract within an organ and surrounding tissue) which was twice surgically repaired in 1997.  His medication treatments varied and did not include systemic immunosuppressant agents.  There were minimal encounter documents in the service treatment record (STR) during the period of 1997 thru 2003 that addressed ongoing treatment of the Crohn’s condition.  In late 2003, he experienced an exacerbation of abdominal cramping with daily bloody stools and subsequently was placed back on medication.  A repeat colonoscopy in March 2004 documented “active Crohn’s disease” and the CI was referred to an MEB.  At approximately 4 months prior to placement on the TDRL, the initial MEB examination dated 6 April 2004, the CI endorsed continuing left sided abdominal cramping with 5-7 bloody loose stools per day.  There was no external physical examination (PE), rather a description of recent colonoscopy findings noted, which were consistent with chronic active colitis and Crohn’s disease.  The examiner concluded that the CI’s condition was “uncontrolled” and was to the point that required him to be close to fixed toilet facilities.

At the VA Compensation and Pension (C&P) evaluation on 29 March 2004; a week prior to the MEB exam, the CI denied weight loss and reported 6-7 bowel movements per day.  The abdominal PE was limited and normal.

At the TDRL re-evaluation on 26 May 2005; 3 weeks preceding the CI’s permanent separation the CI reported occasional abdominal cramping with four non-bloody bowel movements per day.  He was off previous gastro-intestinal (GI) medication.  He reported weight gain.  His PE was brief noting a normal abdomen.  The examiner opined that the chronic GI condition (Crohn’s disease) was in remission.

The Board directed its attention to its rating recommendations based on the evidence just described.  The PEB analogously rated the condition using code 7399-7323 (colitis; ulcerative) at 30% with placement on the TDRL based on moderately severe and poorly controlled GI symptoms.  The VA also utilized the same coding combination.  VASRD code 7323 is proportioned in regards to symptom severity of moderate with infrequent exacerbations rated 10%, moderate severe with frequent exacerbations rated 30%, severe is associated with malnutrition rated 60%, and pronounced associated with anemia, malnutrition, and or serious additional complication rated 100%.  Board members first considered and agreed that absent any degree of malnutrition, the records at TDRL placement supported the 30% PEB rating IAW §4.114.  The Board then focused on the permanent separation rating at the end of TDRL.  The Board agreed that the CI’s overall condition had improved during the period of TDRL noting less daily “non-bloody” bowel movements and “occasional” cramping.  The Board members’ consensus was that the severity of GI symptoms near the time of permanent separation was more closely in line with “moderate” impairment at 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) the Board recommends no change in the 30% TDRL placement rating, with a disability rating of 10% for the Crohn’s disease condition upon removal from the TDRL, coded 7399-7323 IAW VASRD §4.114.

Left and Right Knee Conditions.  The STR indicated that the CI had two separate left knee twisting injuries while playing football in 1994 and 1998, each diagnosed as a sprain and treated with rest and medication.  The case file contained no clinical documents from 1998 to late 2003 when the CI complained of bilateral knee pain “…ongoing for ten years.”  Per orthopedics, his bilateral knee X-ray images were normal.  A magnetic resonance image of the left knee was equivocal for a meniscal tear.  On 7 November 2003, the CI underwent a diagnostic arthroscopy of his left knee.  Post-operative findings were “significant synovitis of the knee joint;” a synovectomy (surgical removal of inflamed joint tissue) was performed.  During the initial MEB examination the CI endorsed persistent left knee swelling associated with daily constant retropatellar (behind the knee) 7/10 knee pain that was aggravated with climbing stairs, inclines, prolonged sitting, standing, and or sudden movements.  “Marked increased pain and swelling is especially noted with walking and repetitive bending of the knee. The [CI] relates that the overall condition of his knee has become worse following the arthroscopy with the joint being more sensitive and now gives out.”  The MEB dictated PE was a summary of the VA exam findings that were performed a week earlier.  That examination revealed a normal gait, with grinding on extension and limited motion.

During the TDRL re-evaluation the CI reported “…decreased amount of pain in his knees.”  The examination was completely normal excepting mildly decreased range-of-motion (ROM) on the left knee (right knee ROM was omitted) and bilateral tenderness about the patellar tendon.  The goniometric 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)	MEB (2808) ~ 5 Mo. Pre-TDRL entry 
(20040305) 	PT ~ 5 Mo. Pre-Sep
(20040304) 	VA C&P ~ 3.25 Mo. 
Pre-TDRL entry
(20040329) 	TDRL NARSUM ~ 3 Weeks Pre-TDRL exit (separation)
(20050405) 	
	Left	Right	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	100	115	70	100	90	100	115	--	
Extension (0 Normal)	0	0	-3	-3	0	0	0	--	
AO Comment	--	--	Stable;
Normal gait	Stable;
Normal gait	Grinding	Grinding 	Tenderness (over the patellar tendon)	Tenderness (over the patellar tendon)	
§4.71a Rating	0%-10%	0%-10%	0%-10%	0%-10%	10%	10%	0%	--	

The Board directed attention to its rating recommendation based on the above evidence.  The VA utilized VASRD code 5260 (limitation of leg flexion) for both left and right knee conditions at 10% each.  The PEB utilized VASRD code 5003 (degenerative arthritis) at 10% for the left knee at TDRL placement, and repeated code 5003 for bilateral knees at TDRL removal.

The Board first considered the left knee condition at TDRL placement.  Although non-compensable limited ROM was present throughout the TDRL period without evidence of objective instability, Board members considered and concluded that the evidence of grinding (an indication of painful motion) clearly supported a 10% rating under VASRD §4.59 (painful motion) at TDRL placement.

The Board next considered the bilateral knee conditions at TDRL removal.  The PEB combined the left and right knee pain conditions under a single disability rating, coded analogously to 5003.  If the Board members judge that separately ratable knee conditions are reasonably 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.  To that end, the evidence for the left knee pain and right knee pain are presented separately; with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Left Knee Condition TDRL Removal.  Although the left knee condition was implicated in the commander’s letter as well as on the permanent profile, such assessments were 14 months prior to the TDRL re-evaluation examination.  The objective clinical evidence at the TDRL re-evaluation clearly established an improved condition noting the absence of effusion, swelling, instability, and joint tenderness to the left knee.  Board members agreed that the tenderness identified about the patellar tendon was minimal and outside the actual knee joint.  The Board could not find evidence within the file that documented any interference of the left knee condition with performance of duties, nor were any physical findings documented by the TDRL re-evaluation examiner that would logically be associated with significant disability.  After due deliberation, the Board agreed that evidence does not support a conclusion that left knee, as an isolated condition, would have rendered the CI incapable of continued service within his MOS; and, accordingly cannot recommend a separate rating for it.

Right Knee Condition TDRL Removal.  Similar to the above left knee description; the right knee was also implicated by the commander and listed on the permanent profile.  Additionally, the TDRL re-evaluation revealed nearly identical objective findings as the left knee.  The Board could not find evidence within the file that documented any interference of the right knee condition with performance of duties, nor were any physical findings documented by the TDRL re-evaluation examiner that would logically be associated with significant disability.  After due deliberation, the Board agreed that evidence does not support a conclusion that right knee, as an isolated condition, would have rendered the CI incapable of continued service within his MOS; and, accordingly cannot recommend a separate rating for it.

Board Consensus.  Board member consensus was that it was reasonable to surmise that the combination of both knees was the condition which rendered him the physical restrictions and therefore, making him unfit for continued military service.  Furthermore, the bilateral diagnosis does support the single 5003 based rating for “2 or more major joints;” thus there is VASRD §4.71a latitude for a bilateral rating in this case.  Member’s agreed that a rating under code 5099-5003 is a good analogy to the pathology of both knees; and, the intended impairment is best described as minimal.  Therefore, 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’s adjudication for the bilateral knee condition at the time of permanent retirement.

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 knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the Crohn’s disease and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB’s adjudication for the TDRL placement and removal periods.  In the matter of the bilateral knee pain at TDRL removal, and IAW VASRD §4.71a, the Board consensus recommends no change in the PEB’s adjudication.

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 20131024, 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, AR20150002972 (PD201301833)

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