RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00255
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060714

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Information System Analyst, medically separated for “bilateral knee pain secondary to patellofemoral pain syndrome” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention in their application.  The CI’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 Physical Evaluation Board (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 - 20060413	VARD - 20070103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain Secondary to Patellofemoral Pain Syndrome 	5099-5003	0%	Left Knee Patellofemoral Pain Syndrome	5260	10%	20060505	
			Right Knee Patellofemoral Pain Syndrome	5260	10%	20060505	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain Secondary to Patellofemoral Pain Syndrome.  The PEB combined the left and right knee conditions under a single disability rating, coded analogously to 5003 and rated 0%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of knee conditions was unfitting and there was no need for separate fitness adjudications.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  Additionally, VASRD §4.31 indicates that “in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met.”  The Board’s initial charge in this case was therefore directed at determining whether the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  Since all examinations were for bilateral knee pain, the evidence for the right and left knee conditions are presented together.  

According to the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain condition began in approximately 2004.  X-rays in January 2006 indicated normal bilateral knees.  MRI of the left knee in February 2006 was also normal.  The bilateral knee condition was determined to be non-surgical by an orthopedist.  Despite conservative treatment, the bilateral knee pain could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “patellofemoral syndrome” for PEB adjudication.  

According to the physical therapy evaluation on 10 March 2006, 4 months prior to separation, range of motion (ROM) measurements were performed with three repetitions.  Physical examination showed extension of 0 degrees bilaterally and flexion of 73 degrees on the left knee and 83 degrees on the right knee (normal 0-140), with bilateral pain-limiting ROM.  At the orthopedic clinic examination on 16 March 2006, the CI reported intermittent knee locking and buckling symptoms.  On examination, both knees displayed no swelling and ligaments were intact.  There was bilateral patellae tenderness and the CI was unable to “fully flex” due to pain.  There was no mention of objective evidence of knee locking on examination.  The examiner rendered a diagnosis of bilateral patellofemoral syndrome.  At the MEB examination (recorded on DD Forms 2807 and 2808) on 16 March 2006, 4 months before separation, the CI reported that minimal activity worsened her knee pain.  Physical examination revealed bilateral tenderness of the patellae and no laxity with normal muscle strength in both lower extremities.  The examiner recorded the CI was unable to do any vigorous activity outside of walking.  The commander’s performance statement dated 24 March 2006 referenced knee pain as limiting the CI’s ability to perform duties.  The commander noted that the CI remained on “profile and under medications to relieve the pain in her knees and/or restore her mobility and physical capabilities.”  The permanent physical profile dated 30 March 2006 listed “Patellofemoral Knee Syndrome” as the only medical condition indicating the lower extremities required restriction and did not meet medical standards.  

At the VA Compensation and Pension (C&P) examination on 05 May 2006, 2 months prior to separation, the examiner recorded that the CI walked briskly without any difficulties, and stated that her “physical limitation is minimal today.”  On examination, she had an extension of 0 degrees bilaterally and flexion of 125 degrees bilaterally with pain and stiffness starting at 110 degrees.  There was no swelling or effusion noted in her knees bilaterally.  There was no evidence of laxity.  There was evidence of pain with palpation of the patellofemoral areas bilaterally.  The CI’s knee x-rays were normal.

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left knee condition with the right knee condition and applied a single 0% rating coded 5099-5003 (degenerative arthritis), citing ‘’full range of knee joint motion without instability.”  The Board members agreed that, as isolated conditions, each knee condition would have rendered the CI incapable of continued service within her MOS, and accordingly each condition merits separate ratings.  Coding and rating features were logically identical.  The VA rated each knee condition 10% coded 5260 (leg, limitation of flexion of), citing “flexion to 125 degrees with functional loss of pain [sic] and stiffness.”  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, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45). 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 10% for the right knee pain condition, coded 5099-5003.

BOARD FINDINGS:  In the matter of the bilateral knee pain condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting left knee condition coded 5099-5003 and rated 10%, and an unfitting right knee condition coded 5099-5003 and rated 10%, both IAW VASRD §4.71a.  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	RATING	
Right Knee Pain due to Patellofemoral Syndrome	5099-5003	10%	
Left Knee Pain due to Patellofemoral Syndrome	5099-5003	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140107, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160014385 (PD201400255)

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