RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00162
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070802

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Signal Support Systems Specialist, medically separated for “chronic bilateral knee pain, right greater than left,” with a disability rating of 0%.  

CI CONTENTION:  The CI contends that he was not treated correctly during the medical board process and that he should be rated at higher percentage per his VA rating.  The applicant’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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 PEB - 20070427	VARD - 20071210	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain, Right Greater Than Left	5099-5003	0%	Musculoligamentous Strain; Status Post Anterior Cruciate Ligament Repair, Right Knee	5299-5260	10%	20070825	
			Musculoligamentous Strain; Patellofemoral Pain Syndrome, Left Knee	5299-5260	10%	20070825	
Scoliosis Secondary to Leg Length Discrepancy	Not Unfitting	Musculoligamentous Strain Lumbar Spine	5237	10%	20070825	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Unbundled Right Knee Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent surgery in May 2006 for right knee anterior cruciate ligament (ACL) repair.  Following recovery from surgery, he experienced persistent duty limiting symptoms of retropatellar pain syndrome with intermittent swelling and difficulty with all activities requiring knee bends and was referred for MEB.  

At the time of the physical therapy ROM study on 28 February 2007, 5 months prior to separation, the CI’s right knee ROM was not limited (see chart above), but he did have pain with flexion and extension.  There were no other pertinent findings in this examination for the right knee.  

At the time of the NARSUM examination on 2 April 2007, the CI was noted to have a “leg length discrepancy on the left leg of approximately 1/2 to 1 inch.”  He had full right knee ROM (see chart above) and no instability or effusion.  “There was a positive apprehension on examination on the right more than the left” with palpable pain of the right patella. 

At the time of the VA compensation and pension (C&P) examination on 25 August 2007, 3 weeks after separation, the examination revealed a normal gait.  There was tenderness and a history of one effusion on the right knee.  There was abnormal tracking of the patella and he had subpatellar tenderness.  He had normal ROM (see chart above), but pain was noted to begin at 100 degrees and end at 120 degrees.  There was no additional limitation of motion on repetitive use and no history of flare-ups.

The Board first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Although the commander indicated that the CI performed well before and after his knee surgery, his profile restricted him from performing the common functional activities required of all Army Soldiers.  Board members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties and accordingly a separate disability rating is recommended.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled knee conditions 0%, using an analogous 5003 code (degenerative arthritis), citing intermittent and slight pain per the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40).  The VA rated the right knee condition 10%, using an analogous 5260 code (limitation of flexion of the leg), citing painful motion.  

A bilateral 10% rating under the provisions of 5003 was considered, but Board members concluded that the physical therapy exam provided satisfactory evidence for painful motion in at least one of the of knee joints; thus, separate joint ratings are indicated IAW §4.71a.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However as indicated above, there was evidence of painful motion with functional loss supporting a 10% rating for the right knee based on §4.59, §4.40 and §4.45.  After due deliberation, considering all of the evidence, the Board recommends a separately unfit determination with a disability rating of 10% for the right knee condition.  

Unbundled Left Knee Condition.  According to STR and the NARSUM, the CI’s left knee condition began in August 2005 without specific injury.  Radiographic studies showed a normal knee.  There was no surgical indication. Despite treatment, the left knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic recurrent knee pain, right more than left, with intermittent effusion (retropatellar pain syndrome)” for PEB adjudication.  

Duty limitations for “knee pain” were recommended by Army profile dated 5 February 2007, including no repetitive squatting, kneeling, or lunging and no jumping, rucking, or marching.  The profile also restricted him from performing most of the common functional activities.  At the time of the physical therapy ROM study on 28 February 2007, 5 months prior to separation, the CI’s left knee ROM was not limited (see chart above) nor was there any evidence of pain with flexion or extension.  According to the commander’s statement dated 21 March 2007, the CI was “still doing his job and [remained] well motivated” and “performed well at work before and after his surgery even though he was limited by profile.”  At the time of the NARSUM examination on 2 April 2007, 4 months prior to separation, the examiner recorded that the CI had “retropatellar pain syndrome with intermittent swelling and difficulty with all activities requiring knee bends.”  He also recorded that the CI couldn’t tolerate “prolonged standing [or] weight bearing activities, (i.e. marching) carrying any loads for prolonged periods of time.  Mounting and dismounting military tactical vehicles and climbing stairs.”  The CI “had extreme difficulty performing the aerobic portion of the APFT with a run.”  The CI also had “difficulty performing the aerobic portion even with a walk or a cycle.”  On examination the CI had full left knee ROM (see chart above) and no instability or effusion.  “There was a positive apprehension on examination on the right more than the left.”  The diagnosis was chronic recurrent knee pain, right more than left, with intermittent effusion RPPS (retropatellar pain syndrome).  

At the time of the VA compensation and pension (C&P) examination on 25 August 2007, 3 weeks after separation, the CI reported that “he [couldn’t] participate in long walking especially up hills due to pain,” but was “able to walk 1-3 miles.”  On examination the CI was noted to have a normal gait and full ROM (see chart above).  The ROM studies for both knees were listed together and indicated that both knees had pain that began at 100 degrees and ended at 120 degrees.  There was no additional limitation of motion on repetitive use and no history of flare-ups.  

The Board first considered if the left knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Although the commander indicated that the CI performed well before and after his knee surgery, his profile restricted him from performing the common functional activities required of all Army Soldiers.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption the bundled left knee condition was reasonably justified as separately unfitting.  The Board then considered its rating recommendation for the unfitting left knee condition at the time of separation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled knee conditions 0%, using an analogous 5003 code, citing intermittent and slight pain per the US Army Physical Disability Agency (USAPDA) pain policy (AR 635-40).  The VA rated the left knee condition 10%, using an analogous 5260 code, citing painful motion.  The NARSUM indicated recurrent pain and effusions with functional loss without mentioning pain on full ROM while the VA examination indicated painful motion for both the left and right knees during the ROM study.  Board members concluded that there was sufficient evidence of painful motion with functional loss supporting a 10% rating based on §4.59, §4.40 and §4.45.  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  No additional functional limitation was evidenced by the examinations.  After due deliberation, considering all of the evidence, the Board recommends a separately unfit determination with a disability rating of 10% for the left knee condition.  

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that scoliosis secondary to leg length discrepancy was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The scoliosis was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  It was reviewed and considered by the Board.  There was no performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation, and 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 contended condition of scoliosis and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5003 and rated 10%, and an unfitting left knee condition, coded 5099-5003 and rated 10%; both IAW VASRD §4.71a.  In the matter of the contended scoliosis condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Bilateral Knee Pain, Right Greater Than Left	Right	5099-5003	10%	
	Left	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131231, 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 XXXXXXXXXXXXXXXXXX, AR20160005533  (PD201400162)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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