RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00099
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Food Service Operations) medically separated for bilateral knee and foot pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  The CI’s profile did allow for an alternate aerobic event to satisfy physical fitness standards.  He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “bilateral knee pain” and “bilateral plantar fasciitis” to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “bilateral knee pain” and “bilateral foot pain secondary to plantar fasciitis” as unfitting, rated 0% and 0% respectively, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy and the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI submitted a contention regarding his bilateral plantar fasciitis but also for hallux valgus (bilateral toe pain) and cubital or carpal tunnel syndrome. The CI’s 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:  

IPEB - Dated 20061020	VA* - (~7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Left knee RPPS	5260	10%	20070716	
			Right Knee Strain	5260	0%	20070716	
Bilateral Foot Pain	5099-5003	0%	Bunion and Hammertoe, S/P Surgical Repair with Plantar Fasciitis, Right Foot	5299-5284	0%	20070716	
			Plantar Fasciitis, Left Foot	5299-5284	0%	20070716	
			Pes Planus	5276	NSC	20070716	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x  13	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20071116 (most proximate to date of separation [DOS]).  
VARD 20140506 increased DC 5299-5284 right foot to 10%, effective 20091014.  

ANALYSIS SUMMARY:  The PEB combined the bilateral knee pain as a single unfitting condition and the bilateral foot pain secondary to plantar fasciitis as a single unfitting condition, each coded analogously to 5003 and rated 0%.  The PEB may have relied on AR 635.40 (B.24 f.) and/or the USAPDA pain policy for not applying separately compensable VASRD codes.  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.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself.  Not uncommonly this approach by the PEB reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  Thus the Board must maintain the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB

Bilateral Knee Pain.  The record shows that the CI was first seen for knee pain in 1999, over 7 years prior to separation, when he reported pain with running slopes and with squatting.  He was treated conservatively with medications, physical therapy (PT), and duty restrictions and able to continue to meet the modified duty requirements.  However, he had persistent pain and was seen periodically over the next few years.  X-rays on 29 October 2003 showed mild arthritis of the right knee.  An MRI of the left knee on 6 August 2004 was normal.  An MRI of the right knee on 24 August 2005 showed Grade I degeneration of the cartilage of the kneecap (chondromalacia patella).  He was seen in orthopedics on 19 September 2005.  A permanent profile restricting running but allowing bicycle riding for fitness (and testing) was recommended.  When seen again in orthopedics on 10 February 2006, the knee was stable and without meniscal signs (cartilage cushions in the knees).  Tenderness was present.  Cross-training into a MOS which did not require prolonged standing was recommended.  At the MEB examination on 10 June 2006, 7 months prior to separation, the examiner noted that the ligaments were normal (stable knee) and that the ROM (range-of-motion) was intact (ROMI).  The narrative summary (NARSUM) was dated 3 days later, 13 June 2006.  It noted the long standing history of knee pain without antecedent trauma.  On examination, there was bilateral tenderness and pain to a patellar grind (pushing down on the kneecap and moving it).  The ROM was slightly limited at 135 degrees (VA normal is 140), but it was symmetric.  The examiner noted that the ROM was full though.  The knees were stable and without signs of meniscal irritation.  No effusion was present.  Painful motion was not documented.  He was diagnosed with bilateral knee pain.  The final profile, dated 6 September 2006, limited him to standing no more than 30 minutes in an hour and allowed walking (but not running) at his own pace.  Repeat X-rays of the knees on 5 February 2007, 5 weeks after separation, were normal.  At a primary care appointment the same day, the knees had no obvious deformity or effusion.  They were non-tender and the ROM was full.  There was no crepitus (an audible or palpable grinding sound/sensation associated with degeneration of the cartilage).  The gait was normal.  Painful motion was not documented.  Muscle wasting was absent.  At the VA Compensation and Pension (C&P) examination performed on 17 July 2007, 7 months after separation, the CI reported that he was working full time for the Postal Service.  He reported constant left knee pain and intermittent right knee pain.  Neither gave way or locked up.  He had not missed work from his knees and had not required any work accommodations.  He was “unsure what his limitations are with running or walking.”  The ROM was normal, but painful on the left.  There was no decrease with repetition.  The knee was stable and without signs of meniscal irritation.  His gait was normal.  He was diagnosed with left knee retro-patellar pain syndrome (RPPS) and right knee strain.  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)	Aviation Medicine
 ~12 Mo. Pre-Sep	MEB ~7 Mo. Pre-Sep	VA C&P ~7 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	Normal	Normal	135	135	140	140	
Extension (0 Normal)	Normal	Normal	0	0	0	0	
Comment	Pain with extension	No pain with motion	No comment on painful motion	Pain with motion	No pain with motion	
§4.71a Rating	10%	0%	0%	0%	10%	0%	

The Board first considered if the knees were separately unfitting.  The ROM was normal on 3 examinations, including one 5 weeks after separation, and showed minimal loss on the MEB examination.  Pain was elicited with motion of the left knee, but not the right.  Chonodromalacia patella was seen on an MRI of the right knee, but not the left.  X-rays of both knees after separation were normal.  The evidence does not reasonably justify a finding that either knee would have been separately unfitting.  The Board then directed attention to its rating recommendation based on the above evidence.  The knees were stable, signs of meniscal irritation absent, and the ROM limitation was not compensable.  The CI denied incapacitation or duty restrictions in his job after separation.  The use of the code 5003, degenerative arthritis, allows for rating both knees.  However, it requires radiographic evidence of joint disease in 2 or more major joints and only the right knee showed any changes and these were not present on the examination closest to separation.  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 bilateral knee pain condition.  

Bilateral Foot Pain.  The CI was evaluated in podiatry on 8 February 2005 for a 1 year history of bilateral foot pain.  He was found to have bilateral flat feet (pes planus) and bunions (hallux valgus).  He was treated with toe pads and orthotics, but had persistent pain.  The pes planus condition was confirmed on X-ray on 26 July 2005.  He underwent a right bunionectomy on 4 October 2005.  He recovered well from the bunionectomy, but continued to have pain from the bilateral pes planus.  The MEB examiner noted that the feet were normal.  The NARSUM documented pes planus with weight bearing (standing).  Dorsiflexion (toes up) was normal, but plantar flexion (toes down) was reduced.  There was mild hallux valgus on the left; it had been surgically corrected on the right.  Painful motion was not documented and the incision was well healed.  The final profile, dated 6 September 2006, limited him to standing no more than 30 minutes in an hour and allowed walking (but not running) at his own pace.  At the VA primary care note dated 5 weeks after separation, the CI reported tingling on the right toe where he had surgery; this improved with sitting.  He had flat feet, but a normal gait.  Muscle wasting was absent.  At the VA C&P examination, the CI reported a painful left arch, but that the right side was not painful.  He used over the counter shoe inserts.  He required no work accommodations and had missed no days of work.  There was minimal tenderness to palpation.  The examination was otherwise unremarkable.  The gait was normal.  X-rays were normal other than the surgical changes.  The ROM of the right ankle was normal; the left was not documented.  

The Board first considered if the feet were separately unfitting.  The CI was noted to have a normal gait at both the primary care visit 5 weeks post-separation and at the VA C&P examination 7 months post separation.  The profile allowed walking “at his own pace and distance”.  The Board determined that the evidence does support a finding that the feet were separately unfitting.  It then directed attention to its rating recommendation based on the above evidence.  The Board considered the codes available for the feet: 5003, degenerative arthritis; 5020, synovitis: or 5284, other injuries of the feet.  The Board found no route to a rating higher than 0% for either foot which was the rating adjudicated by the VA.  Although a rating for each foot at 0%, coded 5284, is supported by the evidence, this provides no advantage to the CI.  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 adjudication for the bilateral foot pain 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  As discussed above, PEB reliance on the USAPDA pain policy for rating the bilateral foot condition was operant in this case and the condition was adjudicated independently of  that policy by this Board.  In the matter of the bilateral knee and bilateral foot pain conditions 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 20131227, 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 XXXXXXXXXXXXXXXXXXXXXXXX, AR20160000309 (PD201400099)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA