RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00297
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E7, Human Resources, medically separated for “chronic bilateral knee pain” and “cold sensitivity bilateral hands,” rated 0% and 0%, respectively, with a combined disability rating of 0%.   

CI CONTENTION:  The CI’s conditions continue to worsen.  Additionally, the CI contended multiple conditions not covered in either the MEB or PEB.  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 based upon a 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 – 20040714	VARD - 20050502   	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	0%	Retropatellar Pain Syndrome with Degenerative Joint Disease [DJD], Right Knee	5010-5260	10%	20050215	
			Retropatellar Pain Syndrome with Degenerative Joint Disease [DJD], Left Knee	5010-5260	10%		
Cold Sensitivity Bilateral Hands	7122	0%	Residuals, Cold Injury, Right Hand	7122	10%		
			Residuals, Cold Injury, Left Hand (Major)	7122	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:   

Bilateral Knee Pain.  In the summer of 2001, this CI had onset of knee pain.  She was treated with medication, physical therapy, and other conservative measures.  Over time, in spite of all treatment efforts, her knee pain persisted and an MEB was initiated.  The MEB narrative summary (NARSUM) was dated 17 June 2004.  On physical examination (PE) of the knees, there was no effusion or edema.  Both knees appeared stable, and all tests for ligamentous laxity were negative.  Grind test was positive on the left.  On range of motion (ROM) testing, there was no restriction.  Extension was 0 degrees, and flexion was 130 degrees bilaterally.  Gait was normal, and neurological examination was normal.

The CI separated from service on 4 February 2005.  Eleven days later, on 15 February 2005, she had a VA Compensation and Pension (C&P) examination.  She reported bilateral knee pain, which was worse with climbing stairs, prolonged standing, or crossing one knee over the other.  She denied any locking, redness, or giving way.  She was not using a cane or knee brace.  On PE, she was in no acute distress, and gait was normal.  Both knees were normal in appearance, without abnormalities.  A click was noted in the left patella (kneecap) with mediolateral movement.  The joint lines were non-tender to palpation bilaterally.  All tests for ligamentous instability of the knees were negative.  ROM was full, and without pain.  There was no weakness or fatigability with repetitive movement.  

The ROM evaluations in evidence which the Board weighed in arriving at its recommendation, are summarized in the chart below.

Knee ROM
(Degrees)	MEB ~8 Mo. Pre-Sep
(20040617)	VA C&P ~11 Days Post-Sep
(20050215)	
	Left	Right	Left	Right	
Flexion (140 Normal)	130	130	140	140	
Extension (0 Normal)	0	0	0	0	

The Board directed attention to its rating recommendation based on the evidence.  The Army PEB chose VASRD code 5099-5003, and assigned a 0% disability rating.  The knees were bundled together, and treated as a single unfitting condition.  The VA unbundled the knees, and assigned a separate disability rating to each knee joint.  The Board evaluated whether or not it was appropriate for the knees to be “bundled” together.  The Board must determine if the PEB’s approach of combining the knees under a single rating was reasonably justified in lieu of separate ratings.  The Board must apply separate ratings in its recommendation if compensable ratings for each knee are achieved IAW the VASRD.  If the Board judges two or more separate ratings are warranted, it must satisfy the requirement each ‘unbundled’ condition was separately unfitting.  After due deliberation, the Board agreed that the evidence does not support a conclusion that each of the knee problems, separately, would have rendered the CI unable to perform her required military duties; therefore, the Board does not recommend a separate rating for each of the knees.  The Board determined that it was appropriate for the right knee to be bundled with the left knee, and treated as a single unfitting condition. 

The Board carefully reviewed the data from the examinations described above.  The Board determined that, IAW VASRD §4.10 (Functional impairment), §4.40 (Functional loss), §4.45 (The joints), and §4.59 (Painful motion), when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional loss and disability due to pain.  There was no path to a higher rating for the knees, since there was no evidence of ligamentous instability, subluxation, or other seriously disabling bone or joint abnormality which would justify a higher rating.  After due deliberation, the Board determined that a disability rating of 10% for the knees was appropriate.  Considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a 10% disability rating for the chronic bilateral knee pain.

Bilateral Hand Condition.  In December 1993, the CI’s hands got cold, and they became numb and white.  She was taken indoors, and her hands returned to normal.  Ever since then, her hands have been sensitive to cold.  When her hands are exposed to cold temperatures, they get numb and tingly.  On 15 November 2002, she was seen by neurology.  The examiner’s diagnostic impression was “Raynaud’s phenomenon.”  At the June 2004 MEB NARSUM examination, PE of her hands was normal.  At the February 2005 C&P examination, she reported that she continued to have cold sensitivity of both hands.  PE of her hands was normal.

Once again, the Board directed attention to its rating recommendation based on the evidence.  The Army PEB chose VASRD code 7122, and assigned a 0% disability rating.  The hands were bundled together, and treated as a single unfitting condition.  The VA unbundled the hands, and assigned a separate disability rating to each hand.  The Board evaluated whether or not it was appropriate for the hands to be “bundled” together.  The Board must determine if the PEB’s approach of combining the hands under a single rating was reasonably justified in lieu of separate ratings.  The Board must apply separate ratings in its recommendation if compensable ratings for each hand are achieved IAW the VASRD.  If the Board judges two or more separate ratings are warranted, it must satisfy the requirement that each ‘unbundled’ condition was separately unfitting.  After due deliberation, the Board agreed that the evidence does not support a conclusion that each of the hand problems, separately, would have rendered the CI unable to perform her required military duties; therefore, the Board does not recommend a separate rating for each of the hands.  The Board determined that it was appropriate for the right hand to be bundled with the left hand, and treated as a single unfitting condition.

The Board carefully reviewed all available evidence.  The Board noted that the Army PEB characterized the unfitting hand condition as “cold sensitivity bilateral hands.”  The condition was coded 7122 (cold injury residual), and rated at 0%.  The VA also used diagnostic code 7122, and assigned a 10% rating to each hand, resulting in a combined rating of 20%.  The Board deliberated at length with regard to the appropriate disposition of this case.  For the reader’s convenience, VASRD §4.104 language for the 10% and 20% ratings under code 7122 is excerpted:

Arthralgia or other pain, numbness, or cold sensitivity plus tissue
loss, nail abnormalities, color changes, locally impaired sensation,
hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular
punched out lesions, or osteoarthritis) ............................................................20 

Arthralgia or other pain, numbness, or cold sensitivity ...................................10

After due deliberation, the Board determined that a disability rating of 10% for the hands was appropriate.  Considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a 10% disability rating for the cold sensitivity bilateral hands.

BOARD FINDINGS:  In the matter of the chronic bilateral knee pain, the Board unanimously recommends a disability rating of 10%, coded 5299-5260, IAW VASRD §4.10, §4.40, §4.45, and §4.59.  In the matter of the cold sensitivity bilateral hands, the Board unanimously recommends a disability rating of 10%, coded 7122, IAW VASRD §4.104.  There were no other conditions within the Board’s scope of review for consideration.    

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

CONDITION	VASRD CODE	RATING	
Chronic bilateral knee pain 	5299-5260	10%	
Cold sensitivity bilateral hands	7122	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140108, 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 AR20160013045  (PD201400297)

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