RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01855	
BRANCH OF SERVICE:  Army 	BOARD DATE:  20150409
SEPARATION DATE:  20040630		

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Basic Trainee) medically separated for chronic bilateral knee pain.  The bilateral knee condition could not be adequately rehabilitated to complete her initial entry training or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The bilateral knee condition, characterized as “retropatellar pain syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (right acromioclavicular separation and pes planus) for PEB adjudication.  The informal PEB adjudicated “retropatellar pain syndrome” as unfitting, rated for “slight and constant” pain at 10%, citing criteria 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 (released from active duty due to medical disability).  

CI CONTENTION:  “The injuries to my knees, back, shoulder, and neck were more severe than the board evaluated for.  I also should have been evaluated for an eye condition caused by the multiple chalzions I developed while in and subsequently out of service.”  

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:  
   
Service IPEB – Dated 20040407	VA - (4.7 Months Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain
	5099-5003	10%	Patellofemoral Syndrome, Left	5257	0%	20040901	
			Patellofemoral Syndrome, Right	5257	0%	20040901	
Right Acromioclavicular Separation	Not Unfitting	Right Shoulder Impingement Syndrome	5010-5201	10%	20040901	
Pes Planus	Not Unfitting	Pes Planus	5276	NSC	20040901	
Other x 0  (Not in Scope)	Other x 2 (Not in Scope)		
Rating:  10%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20041122 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for disability rating.  If the members judge that separately ratable conditions are 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.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the right and left knee conditions are presented; with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Bilateral Knee Pain.  The narrative summary (NARSUM), dated 18 February 2004, stated the CI’s bilateral knee pain began in March 2003 during basic training after another “160 pound guy hit her right knee with his foot.”  The knee pain was progressive and unresponsive to physical therapy, medications, and profiling.  The pain was constant, caused sleep disturbance, and required medications.  At a primary care visit dated 11 July 2003, 11 months prior to separation, the CI reported bilateral knee pain.  The examiner documented painful and decreased range-of-motion (ROM), and stated that she could “not totally straighten the right leg.”  At an orthopedic visit dated 31 July 2003, the examiner documented no effusion, no crepitus, no instability, and full active ROM with 5/5 muscular strength (normal is 5/5).  A diagnosis of retropatellar pain syndrome was rendered.  Radiographic studies dated 1 May 2003 documented normal tendons, ligaments, and cartilaginous tissues.  The records were silent for any knee complaints until a bilateral knee X-rays dated 4 February 2004 documented a right-sided suprapatellar effusion with no evidence of significant bone or joint abnormality in either knee.  At the MEB examination dated 6 February 2004, approximately 5 months prior to separation, the CI reported giving way, locking, popping, swelling, and a grinding sensation with activity.  She reported that the pain was constant (right greater than left) and caused sleep disturbance.  The CI reported wearing a brace for support and stabilization of the knee and taking anti-inflammatory medications daily.  The MEB physical examination documented bilateral patellar tenderness to palpation, grinding without effusion, and no signs of instability (negative Lachman’s and Mc Murray).  The right knee flexion ROM was 0-135 degrees (normal knee ROM is 0-140 degrees) and the left knee was negative 2-135 degrees.  

At the VA Compensation and Pension (C&P) examination performed 2 months after separation, the CI reported popping, locking and grinding on a constant basis, difficulty walking, bending, kneeling and climbing up stairs.  She reported lost time at work at least once per week because of knee pain.  The examiner documented normal appearing knees with full ROM bilaterally (0-140 degrees each), and marked crepitus on ROM.  There was no instability or pain or other limitations after repetition.  Radiographic studies were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB adjudicated the bilateral “retropatellar pain syndrome” as unfitting, rated for “slight and constant” pain with a disability rating of 10%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy and coded as 5099-5003 (analogous to degenerative arthritis).  The VA granted service-connection for both knees and rated them separately at 0% coded as 5257 (Knee, other impairment of).  

The Board first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting.  Although the treatment records provided evidence that the right knee was more painful than the left, there were no fitness distinctions evident.  The unit commander stated that the CI could not perform her duties citing “chronic knee pain.”   Both knees were permanently profiled.  The NARSUM examiner implicated both knees as failing to meet retention criteria (IAW AR 40-501, 3-41 e).  Members agreed that, based on the evidence, there was a questionable basis for arguing that each knee was separately unfitting and that it was reasonable to surmise that the combined functional impairment from both knees rendered the CI unfit to perform her duties.  The Board noted the diagnosis of bilateral retropatellar syndrome, IAW DoD Table of Analogous codes, is coded analogous to 5003 and that VASRD 5003 allows for a single rating of “2 or more major joints” in the absence of compensable limitation of motion.  There was no evidence of knee limitation of flexion to 60 degrees, extension limitation to 5 degrees, or ankylosis for compensable limitation of motion.  There was no evidence of occasional incapacitating bilateral knee retropatellar pain exacerbations for a 20% rating under VASRD 5003.  Members agreed, therefore, that there was insufficient evidence for recommending separate right and left knee disability ratings in this case.  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 single unfitting bilateral retropatellar pain syndrome determination and that a disability rating of 10% was appropriately recommended in this case.  

Contended PEB Conditions.  

Right Acromioclavicular Separation.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right acromioclavicular (AC) separation was 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.  

At a primary care visit dated 2 December 2003, the CI reported a fall onto the right shoulder causing pain, stiffening, decreased ROM and interference with sleep.  Examination documented symmetric shoulder height with decreased ROM secondary to pain.  Radiographic studies documented normal alignment of the AC joint, with possible AC joint separation.  At the MEB examination dated 6 February 2004, 5 months prior to separation, the CI reported a “no lifting profile” for her right arm.  She stated “full ROM now, but painful.  Constant, without sleep disturbance.”  The MEB examiner documented full ROM of the left shoulder and mild decreased internal rotation of the right shoulder, good strength, shoulder pain with abduction and internal rotation.  The NARSUM examiner referenced bilateral AC dislocations from studies dated 4 December 2003.  No formal examination was performed.  At the VA C&P examination dated 1 September 2004, 2 months after separation, the CI reported grinding, popping, pain in the right shoulder when reaching overhead; decreased strength and ROM; and once weekly flares that lasted 6 hours, that prevented her from lifting overhead.  The examiner documented grossly normal shoulder with 180 degrees of flexion (normal 180 degrees), 160 degrees of abduction (normal 180 degrees) with pain.  On repetition, shoulder ROM was limited by pain, but not by fatigue, weakness, lack of endurance or incoordination.  Radiographic studies of the right shoulder demonstrated a “negative right shoulder.”  The examiner diagnosed “right shoulder impingement syndrome… and that the functional effect …on the veteran’s usual occupation and daily activity [was] minimal.”  

The right acromioclavicular separation was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  It was reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that the right acromioclavicular separation significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right acromioclavicular separation and 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 discussed above, PEB reliance on the USAPDA pain policy for rating bilateral knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  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 right shoulder condition, 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, 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 20131008, 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 XXXXXXXXXXXXXXXXXXXXXXX, AR20150012513 (PD201301855)

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