RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00084
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Trainee) medically separated for bilateral knee pain.  The bilateral knee condition could not be adequately rehabilitated to meet the physical requirements to complete initial entry training.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Bilateral patellar tendinitis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (periorbital fracture and sinusitis) for PEB adjudication.  The Informal PEB adjudicated “chronic bilateral patellar tendinitis” as unfitting, rated at 0% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  Her condition continues to worsen and negatively impact her daily activities.  Her complete submission is at Exhibit A.  

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 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 20070913	VA - (3 Mo. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Patellar Tendinitis	5024	0%	Patellofemoral Syndrome, Bilateral	5009-5024	10%	20071214	
Periorbital Fracture	Not-Unfitting	Diplopia in Right Gaze, Resulting from Fracture	6099-6016	10%	20071214	
Sinusitis	Not-Unfitting	No VA Entry	
Other MEB/PEB Conditions x 0  (Not in Scope)	Other x 4 	
Rating:  0%	Combined Rating:  30%	
Derived from VA Rating Decision (VARD) dated 20090428 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY: 

Chronic Bilateral Patellar Tendinitis Condition.  A note in the service treatment record (STR) dated 9 January 2007 indicated the CI’s bilateral knee pain began after basic training, which finished in October 2006.  Physical therapy was instituted where it was noted there was a full range-of-motion (ROM) of both knees.  The diagnosis of patellofemoral (PF) dysfunction was made in February 2007 and was treated with the medications, ketorolac (a nonsteroidal anti-inflammatory drug (NSAID)) intramuscularly and piroxicam (an NSAID) orally.  Physical therapy exercises were then modified to treat the PF dysfunction.  Knee pain worsened and a short course of an oral steroid (methylprednisolone) was prescribed.  X-rays of the knees were normal on 12 February 2007.  Naproxen (NSAID) replaced the piroxicam, which was replaced by acetaminophen and meloxicam (NSAID) in March 2007.  Orthopedic evaluation in April 2007 indicated the CI was placed on profile for 4 weeks; physical therapy was held; patellar (kneecap) Cho-Pat strapping braces for weight bearing were instituted; and oral steroids were prescribed for a 3-week course for continued knee pain.  An orthopedic examination dated 25 April 2007 of the CI’s back, hips, and legs revealed no evidence of point tenderness or decreased ROMs.  A whole body bone scan dated 14 May 2007 was normal.  Meloxicam was discontinued and piroxicam was resumed; physical therapy was continued.  In June 2007 after several months of knee pain, the Family Practice diagnosis was modified to be patellar tendonitis (also called tendinitis), which was in concert with the orthopedic diagnosis 2 months earlier.  A note in July 2007 indicated that despite adequate care for the PF syndrome, no surgical intervention was indicated and the CI was unable to perform the physical demands of her enlistment.  ROM measurements on 15 August 2007 for the right knee were 125, 120, and 120 degrees flexion with pain at the end of the ROMs and 0 degrees extension three times and left knee flexion measurements were 125, 128, and 130 degrees with pain at the end of the ROMs and 0 degrees extension three times.  Lachman’s test (to test for instability) bilaterally was 1+.

At the MEB examination on 3 July 2007, the CI reported on DD Form 2807-1, Report of Medical History, she had patellofemoral syndrome, tendonitis and used alignment knee braces.  The MEB physical examiner noted on DD Form 2808, Report of Medical Examination, tenderness, but complete ROMs with a positive Clarke’s sign (to assess PF and chondromalacia syndromes).  The examination was otherwise unremarkable and there was no effusion.  A permanent L3 profile was issued for knee pain for patellar tendonitis on 27 July 2007.  The commander’s statement dated 10 August 2007 indicated the CI was physically incapable of reasonably performing her duties as an Integrated Family of Test Equipment (IFTE) Operator/Maintainer due to chronic knee pain from patellar tendonitis.

The MEB narrative summary (NARSUM) dated 3 September 2007 noted the CI’s knee pain, which began in October 2006, was constant but minimal unless her activity increased by having to run, march, squat, or climb, then her pain became severe; however, she controlled the pain well without medication simply by limiting her activity.  X-rays, a bone scan, and a rheumatologic workup were negative.  ROM measurements were performed by physical therapy with flexion limited only to a mild degree.  There was no evidence of effusions or joint tenderness.  The CI’s gait was normal as were her balance and motor strength, which was 5/5 in all major groups tested.  The remainder of her neurologic examination was unremarkable.  The NARSUM author’s diagnosis was bilateral patellar tendinitis unresponsive to prolonged and conservative traditional therapy including physical therapy, rest, NSAIDs, and evaluation by orthopedic surgeons.  He opined the CI might get back to a normal level of functioning with more time and noted her functional status was good at the time of the NARSUM examination.

At the VA Compensation and Pension (C&P) examination dated 7 December 2007, performed 10 weeks after separation, the CI reported a history of chronic bilateral knee pain aggravated by climbing stairs or running.  The examination was “significant for vague bilateral knee tenderness, nothing specific.”  There was “full range of motion in all extremities and both knees.”  In a VA C&P examination dated 14 December 2007, performed 11 weeks after separation, the CI reported pain, stiffness, swelling, giving way, and locking intermittently of both knees.  She used a brace on each knee.  The ROM measurements of the knees were 0-130 degrees with pain beginning at 120 degrees.  With repetitive movements, pain was the same.  There was mild edema bilaterally, with decreased bilateral quadriceps muscle power to 4/5, and tenderness anteriorly bilaterally.  Her ambulation was normal without an assistive device, and she had mild varus (inward angulation) bilaterally of the knees and no ankylosis. 

The 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)	PT ~6 Weeks Pre-Sep	C&P General 
~10 Weeks Post-Sep	C&P Joints
~11 Weeks Post-Sep	
	Left	Right	Left	Right	Left	Right 	
Flexion (140 Normal)	125/128/130	125/120/120	FROM	FROM	120 (130 w/reps)	120 (130 w/ reps)	
Extension (0 Normal)	0	0	FROM	FROM	0	0	
Comment	With pain at the end of the ROM; Lachman’s test 1+	With pain at the end of the ROM; Lachman’s test 1+			With pain	With pain	
§4.71a Rating	PEB 0% (bilateral knees)	-	-	VA 10% (bilateral knees)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5024 (Tenosynovitis) for bilateral patellar tendinitis with no objective findings.  The VA assigned a 10% rating using code 5009-5024 (Arthritis, other types-Tenosynovitis) for bilateral patellofemoral syndrome.  The Board sought a route for a higher rating noting that code 5024 is rated on limitation of motion of affected parts as degenerative arthritis.  However, neither the MEB nor the VA ROM measurements are ratable IAW limited motion of either flexion or extension.  Therefore, the Board considered the analogous code 5099-5003 to be applicable.  

Board Approach to PEB Consolidated Rating. The PEB combined the left knee pain and the right knee pain under a single rating, coded 5024, but rated it 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.  IAW DoDI 6040.44, if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.  The Board’s initial charge in this case was directed at determining whether the PEB’s combined adjudication was justified in lieu of separate ratings.  In this case, bilateral (left knee and the right knee) patellar tendinitis was profiled, albeit under the catch-all term “knee pain from patellar tendonitis,” was considered to fail retention standards, and was implicated by the NARSUM and in the commander’s statement.  Members agreed that each joint is separately unfitting and that identical coding and ratings are applicable.  In view of noncompensable ROMs and objective pain noted on a VA examination proximate to separation, use of analogous code is reasonable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition and a disability ration of 10% for the right knee condition.  

Periorbital Fracture and Sinusitis.

The Board’s main charge is to assess the fairness of the PEB’s determination that the periorbital fracture and sinusitis conditions 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.  The periorbital fracture and sinusitis conditions were not profiled or implicated in the commander’s statement, (although frequent migraine headaches, which are not in the scope of review, were mentioned) and were not judged to fail retention standards.  

The CI sustained injuries to the face in a motor vehicle accident on 5 July 2007 and was seen in an Emergency Room where pertinent workup revealed a left nasal ala fracture and a large medial wall orbital fracture (blow-out fracture) with herniation of medial orbital fat into the ethmoid air cells along with a small amount of fluid and a CT cervical spine examination was normal.  Treatment consisted of amoxicillin clavulanate, an antibiotic, Lortab (hydrocodone, a narcotic and acetaminophen, a pain reliever), which caused nausea, and promethazine to treat the nausea.  At an optometry examination on 12 July 2007 the CI indicated she could not blow her nose since the fracture.  On examination there were no signs of retinal detachment.  The CI saw an orbital and ophthalmic plastic and reconstructive surgeon on 16 July 2007 after being told by an ENT specialist he could not repair the left orbit blowout fracture.  The ophthalmic surgeon indicated the CI did not have any of the criteria for surgery on the eye.  On 3 August 2007, the CI complained of headaches and facial pressure with congestion, cough, and chills and rhinorrhea (running nose) was present on examination.  The diagnosis of sinusitis was made and treatment was with co-trimoxazole DS (an antibiotic) and a mucolytic/decongestant medication (Entex-PSE).  A Family Practice note dated 10 August 2007 indicated the CI reported she was doing well after undergoing orbit and nose surgery; however primary evidence was not in the case record.  A steroid nasal spray (fluticasone propionate) was added to the treatment protocol.  A note from the physical examination clinic dated 17 August 2007 indicated the CI had been seen by ENT (otolaryngology) and had done well with conservative therapy, and a secondary sinus infection as a result of her facial fracture was responding to antibiotics.  A note on 17 August 2007 indicated ENT surgery was set for the next week.  Allergic rhinitis was treated with the nasal steroid spray and loratadine, a non-sedating antihistamine in September 2007.  On 27 August 2007, the CI was placed on post-operative convalescent leave until 9 September 2007 at the suggestion of the ENT surgeon.  The NARSUM dated 3 September 2007 indicated the CI sustained a left orbital fracture and concomitant sinus infection, which had responded well with conservative therapy of antibiotics that had nearly been completed and the pain from the orbital fracture was well controlled.  A VA examination dated 6 December 2007 noted a report of CT scan evidence of a left orbit medial wall fracture with some entrapment of tissue and a report of slight diplopia on extreme right gaze.  On examination the CI had mild tenderness of the inferior medial orbital wall.  The diagnosis, not in the scope of review, of diplopia in right gaze, S/P left medial wall fracture not correctable by prism lenses was made.  A VA otolaryngology note dated 25 January 2008, 4 months post-separation, indicated the CI had intermittent frontal headaches, clear rhinorrhea, nasal congestion without epistaxis (nasal bleeding) or purulent discharge.  A CT scan of the brain dated 8 January 2009 was unremarkable and the visualized mastoid air cells and paranasal sinuses were unopacified and there were no fractures.  A CT of the sinuses demonstrated hypoplastic (small) frontal sinus[es] with no disease.  The examiner’s assessment was allergic rhinitis and nasal septal deviation and treatment was with normal saline spray and Nasalide (flunisolide, a corticosteroid) spray.

The aforementioned was reviewed and considered by the Board.  There was no performance based evidence from the record that either the sinusitis or the periorbital fracture conditions 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 sinusitis and periorbital fracture contended conditions and so no additional disability ratings are 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the chronic left patellar tendinitis condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the chronic right patellar tendinitis condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended periorbital fracture and sinusitis conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Left Patellar Tendinitis	5099-5003	10%	
Chronic Right Patellar Tendinitis	5099-5003	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131218, 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 XXXXXXXXXXXXXXXXXXX, AR20160000315 (PD201400084)

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,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization 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