RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00433
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Multichannel Transmission Systems Operator-Maintainer) medically separated for bilateral knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The condition “bilateral knee pain, left greater than right (slight/constant)” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “chronic bilateral knee pain secondary to patellofemoral syndrome (PFS),” as unfitting, rated 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant makes no specific contention in his application.  His 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 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:  

IPEB - Dated 20060117	VA* - (~4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain Secondary to PFS	5099-5003	10%	PFS, Left Knee	5299-5262	10%	20060705	
			PFS, Right Knee	5299-5262	10%		
Other MEB/PEB Conditions x 0 	Other x 2	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20060921 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain Secondary to Patellofemoral Syndrome.  The CI first noted atraumatic knee pain in 2003, initially on the right and then left.  The knees were stable and the range-of-motion (ROM) was normal.  Over the course of the next few years, he was treated with medications, physical therapy (PT), and duty modifications without resolution of his pain.  By report, X-rays were normal.  A bone scan on 28 June 2005 was consistent with generalized overuse without evidence for stress fractures.  It was repeated on 4 August 2005 and thought to be consistent with patello-femoral pain syndrome (PFPS, degeneration changes of the kneecap).  In PT on 1 November 2005, the CI was noted to have a painful gait, but the ROM was within functional limits.  An X-ray of the right knee on 30 November 2005 was normal as were X-rays of both knees at the VA on 5 July 2006.  The narrative summary (NARSUM) was dated 30 November 2005, 3 months before separation.  The CI reported ongoing knee pain, “popping” in his knees, and that his left knee had “given out” one month prior.  On examination, he walked “very slowly and stiffly.”  The knees were stable and signs of meniscal (cartilage cushions) absent.  There was no swelling, warmth, or redness, but the CI was tender to light touch.  At the MEB examination on 7 December 2005, 2 months before separation, the CI reported bilateral knee pain without specific trauma.  The MEB physical examiner noted subjective knee pain with ROM and palpation of the knees.  Two days later in PT, the CI had formal ROM measurements (below).  The examiner wrote that during flexion while supine (on his back), the CI “had to curse repeatedly [with] each degree he was able to achieve.”  This reaction was not present with flexion while sitting, walking, or stair climbing.  The CI walked into the clinic without gait abnormalities, but formal examination of this gait was inconsistent.  He was also able to ascend stairs without use of his upper extremities.  At the VA Compensation and Pension (C&P) examination performed on 5 July 2006, 4 months after separation, the CI denied subluxation or dislocation, but that he had trouble squatting (worked as a mechanic) and no longer played basketball, baseball, or soccer.  The Board noted that a C&P examination remote from separation recorded that he enjoyed playing baseball though.  His posture and gait were normal without the use of ambulatory aids.  The CI showed painful motion, but the knees were stable, guarding absent, and no abnormal movement was present.  A sign of meniscal irritation was positive on the right, but not the left.  The X-rays were normal as noted above.  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)	MEB ~3 Mo. Pre-Sep	VA C&P ~4 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	105	110	140	140	
Extension (0 Normal)	0	0	0	0	
Comment	Painful Motion	Painful Motion	
§4.71a Rating	10%	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the knees as a combined condition at 10%, coded 5099-5003 (analogous to degenerative arthritis).  The VA rated each knee at 10%, coded 5299-5262 (analogous to impairment of the fibula and tibia [lower leg bones]), but later changed the code to 5260 (limitation of flexion), effective 16 March 2014 without changing the ratings.  The Board noted that the CI was found unfit for bilateral knee pain and considered if a higher rating for each knee was supported.  X-rays of the knees were normal.  The initial bone scan showed changes from overuse and the second was thought to be consistent with PFPS, a non-specific diagnosis associated with abnormal tracking of the kneecap.  The knees were stable and only one examination showed signs of meniscal irritation.  The ROM was reduced on the PT examination, but the examiner noted inconsistencies in the examination in both the gait and the reported pain with motion.  The VA examination showed painful, but full ROM.  The limitation of motion on the MEB examination is not ratable and the knee was stable without signs of meniscal irritation other than one examination.  VASRD §4.59 (painful motion) requires that at least the minimum rating for the joint(s) be applied if a higher rating is not supported (by loss of motion, etc.)  Painful motion is present on both the MEB and VA examinations.  The minimum rating for both knees is 10% using the 5003 code for degenerative arthritis of two major joints without incapacitation.  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.  

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 knee pain condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the chronic bilateral knee pain condition 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 20140113, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

26 AUG 2016

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 XXXXXXXXXXXXXXXXXXXX, AR20160010222 (PD201400433).

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