RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01895
BRANCH OF SERVICE:  Army	BOARD DATE:  20150304
Separation Date:  20041115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Finance Specialist) medically separated for chronic bilateral knee and low back conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “bilateral chondromalacia patella” and “mechanical low back pain” conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic bilateral knee pain” and “chronic subjective low back pain (LBP)” as unfitting, rated 10% and 10% respectively with likely application of the of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her 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 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:

IPEB – Dated 20040520	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	10%	Retropatellar Pain Syndrome with Chondromalacia, Right Knee	5099-5014	10%	20040802	
			Retropatellar Pain Syndrome with Chondromalacia, Left Knee	5099-5014	10%	20040802	
Chronic Subjective LBP	5299-5237	10%	Lumbar Strain	5237	0%	 20040802	
Other x 0 (Not in Scope)	Other x  0	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050112 (most proximate to date of separation [DOS])
ANALYSIS SUMMARY:  The PEB rated chronic bilateral knee pain under the single code 5020 (Synovitis).  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, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each disability rating.

Chronic Bilateral Knee Condition.  The CI developed right knee pain while walking downstairs in June 2003 after a pulmonary function test.  She was seen for complaints of swelling, pain on ambulation and an inability to bend her knee.  There were physical exam findings of patellar grind, and a positive apprehension test for patella hypermobility.  The examiner diagnosed patellofemoral pain syndrome (PFPS) and ordered a knee brace and a non-steroidal anti-inflammatory drug (NSAID).  The right knee improved with better range-of-motion (ROM) as the pain subsided.  In June 2003, the CI developed left knee swelling and she was seen by Orthopedics for bilateral knee pain.  The Orthopedist noted physical exam findings of bilateral patella femoral grind.  The examiner diagnosed bilateral PFPS and restricted the CI to Quarters for 12 hours and no physical therapy (PT) test, however an ability to run at own pace.  The medical examiner noted a positive compression test, right knee ROM flexion of 135 degrees and left knee ROM flexion of 140 with bilateral pain at end range; and an abnormal gait which favored the right knee.  The examiner diagnosed bilateral PFPS and noted that a bilateral knee X-ray was normal.  The Orthopedist documented chronic bilateral knee PFPS with physical exam findings of crepitus, subluxation, quad weakness; patellar tilt and lateral facet tenderness to palpation.  The primary care examiner noted physical exam findings of bilateral crepitus and limited ROM.  The Orthopedist noted bilateral knee pain swelling and +1 instability.  There were physical exam findings of medial and lateral joint line tenderness.  A left knee X-ray was normal.  The MEB Orthopedic Addendum documented radiology evidence of bilateral mild patellar chrondromalacia.  The examiner changed the American Medical Association (AMA) pain rating to moderate and frequent.  The MEB narrative summary (NARSUM) exam performed 10 months prior to separation documented that the CI had difficulty performing unit details that required lifting and manual labor.  The MEB NARSUM physical exam findings are summarized in the chart below.  A right knee magnetic resonance imaging (MRI) showed a small triangular free body in the lateral aspect of the knee joint; the CI had not complained of any knee locking at that time.  The VA Compensation and Pension (C&P) exam approximately 3 months after separation documented continued bilateral knee pain with occasional swelling and locking on one occasion, and bilateral knee pain made worse with prolonged standing and walking.  The VA C&P physical exam findings are summarized in the chart below.

There were four goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Knee ROM (Degrees)	NARSUM ~10 Mos. Pre-Sep	VA C&P ~3.5 Mos. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	140	140	140	140	
Extension (0 Normal)	0	0	0	0	
Comment	Normal gait; Pos. tenderness to palpation (TTP) & patellar grind; No instability or effusion; Normal strength & reflexes	Normal gait; Pos. tenderness to palpation & patellar grind; No instability or effusion; Normal strength & reflexes	Normal gait; Pos. TTP; No effusion or painful motion; No evidence of instability or locking	
§4.71a Rating	0%	0%	0% (VA 10%)	0% (VA 10%)	
PEB 10%	

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, there are no unilateral distinctions with regards to clinical features or fitness considerations.  It is speculative to conclude that the disability confined to a single knee would have rendered the CI incapable of performing her MOS within her Rating; and, it is reasonable to surmise that it was the combined mild impairment of both knees which rendered her unfit.  Furthermore, the bilateral diagnosis is supported by a single 5003 based rating for “2 or more major joints”; thus there is VASRD §4.71a latitude for a bilateral rating.  Members agreed that there were insufficient grounds for recommending separate right and left knee disability ratings in this case.  The PEB coded the chronic bilateral knee pain condition as 5099 analogous to 5003 (degenerative arthritis) and rated at 10% with possible application of the USAPDA pain policy.  The VA coded the retropatellar pain syndrome with chondromalacia and right knee retropatellar pain syndrome with chondromalacia, left knee conditions separately as 5099-5014 (Osteomalacia) and rated both conditions at 10% each.  There was no specific injury noted, both exams documented non-compensable knee ROM without evidence to adequately support painful motion IAW §4.59.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.40 (functional loss), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic bilateral knee pain condition.

Chronic Subjective Low Back Pain Condition.  The CI developed LBP in 2002 which waxed and waned.  She was referred to PT and received treatment throughout 2002.  The Orthopedist documented that the LBP developed back pain after she had been doing sit-ups on the hard ground.  She reported that she had the pain for 2 months, which worse by sitting in a chair, walking for more than 15 minutes and after she went on a march with her backpack.  The pain was relieved by a NSAID.  The physical exam findings were normal and the examiner diagnosed lumbar spine strain.  A lumbar spine MRI was normal.  The specialist discharged the CI on 19 August 2002 because she reported back pain only with sit-ups or push-ups, the physical exam was normal and the MRI was normal.  A lumbar spine X-ray was normal.  The MEB Orthopedic Addendum documented that all radiology of the lumbar spine was normal.  The examiner changed the AMA pain rating to moderate and frequent.  The MEB NARSUM exam performed 10 months prior to separation documented that the CI had intermittent episodes of LBP.  The MEB NARSUM physical exam findings are summarized in the chart below.  The VA C&P exam documented no complaints of back pain at this exam.  The VA C&P physical exam findings are summarized in the chart below.

Thoracolumbar ROM (Degrees)	NARSUM 10.17 Mo. Pre-Sep	VA C&P 3.53 Mo. Post-Sep	
Flexion (90 Normal)	“finger tips to floor”	90	
Combined (240)	-	240	
Comment	Normal gait; No spasm or tenderness; Normal strength, reflexes & sensation	Normal gait; No tenderness or painful motion; No Deluca criteria	
§4.71a Rating	(PEB 10%) 0%	0% (VA 0%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the chronic subjective LBP condition as 5299 analogous to 5237 (Lumbosacral or cervical strain) and rated at 10%.  The VA coded the lumbar strain condition as 5237 and rated at 0%.  The General Rating Formula for Diseases and Injuries of the Spine considers pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease.”  The MEB NARSUM physical exam was normal.  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 adjudication for the chronic subjective LBP condition.

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, possible PEB reliance on the USAPDA pain policy for rating the chronic bilateral knee pain 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 condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic subjective low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20131007, 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 XXXXXXXXXXXXXXX, AR20150011060 (PD201301895)

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:

CF: 
(  ) DoD PDBR
(  ) DVA