RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00508
BRANCH OF SERVICE:  Army	BOARD DATE:  20150213
SEPARATION DATE:  20050311

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Light-Wheel Vehicle Mechanic) medically separated for bilateral knee.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB).  The “chondromalacia patellae, patellofemoral syndrome, bilateral” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated chronic pain of the right and left knee as unfitting rated 10%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “It has been 8 years since discharge.  The condition of my knees has only worsened.  I am still unable to run or lift heavy objects without pain.  I am still on RX NSAID’s.  This impacts my daily working life.”

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 20050208	VA* - (~1 Mo. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right and Left Knee	5099-5003	10%	Chondromalacia and Patellofemoral Syndrome, Left Knee	5099-5014	10%	20050405	
			Chondromalacia and Patellofemoral Syndrome, Right Knee		10%		
Other x 0 	Other x 2	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050701 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY: The PEB combined the left and right knee conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis).  Although the VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Bilateral Knee Condition.  Review of the service treatment record revealed complaints of bilateral knee pain for several years.  There was no history of injury or trauma.  Pain was initially episodic and associated with activities like running, but progressed to the point that it was experienced at rest.  Imaging studies found evidence of mild chondromalacia of the left patella (softening or degeneration of the kneecap cartilage).  The right knee was radiographically normal.  The bilateral knee pain condition did not improve sufficiently despite physical therapy, activity modification, pain medication and joint injections.

On 30 September 2004 (5 months prior to separation), the narrative summary (NARSUM) reported that the left knee was painful all the time, while right knee symptom frequency varied.  Left knee pain was aggravated by prolonged standing, running, squatting and lifting.  Both knees were painful when going up or down stairs.  Examination showed no swelling in either knee.  Ligaments were stable and there was no sign of patellar instability.  Compression of the patella of each knee caused pain.  Mild crepitus was present bilaterally.  At the MEB exam on 25 October 2004, the CI reported that he required hinged braces for each knee to provide stability.  At an orthopedic assessment on 28 October 2004, the CI reported bilateral knee pain for several years, left worse than right.  The commander’s statement on 19 November 2004 (4 months prior to separation) indicated that pain and a restrictive profile interfered with duty performance.  Standing longer than 30 minutes was reported to cause pain.

At the VA Compensation and Pension (C&P) exam performed a month after separation, the CI reported taking pain medication twice per week for knee pain that was aggravated by prolonged standing, running, jogging, and climbing stairs.  Examination showed a brisk walk without use of assistive devices.  He could fully squat and get on the examination table without difficulty.  Examination of each knee showed no swelling, tenderness or painful motion in either knee.  Pain with patellar compression was absent.  All ligaments of each knee were stable.  There was no additional limitation after repetitive motion.  X-rays of the knees were normal.

The goniometric range-of-motion 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)	Ortho ~4.5 Mos. Pre-Sep	MEB ~4 Mos. Pre-Sep	VA C&P ~1 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	130	130	114, 118, 116	118, 120, 117	135	135	
Extension (0 Normal)	0	0	0, 0, 0	0, 0, 0	0	0	
Comment					+Crepitation	
§4.71a Rating	0% or 10%*	0% or 10%*	0% or 10%*	0% or 10%*	0% or 10%*	0% or 10%*	
		*Conceding §4.59 (painful motion)

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each knee remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB’s DA Form 199 reflected application of the VASRD analogous 5003 code for rating the right and left knee pain conditions together at 10%.  The Board agreed that it would be overly speculative to conclude that either knee was not unfitting.  Clinical notes reflected difficulties with both knees and a bilateral condition was profiled.  Each knee would have likely rendered the CI incapable of continued service within his MOS; and, accordingly each condition merits separate ratings.  The VA assigned a 10% rating for each knee condition under an analogous code 5014 (osteomalacia) for a non-compensable degree of reduced flexion.  The Board considered separate ratings of 10% for each knee.  Although mild limitation of flexion was noted by all examinations, the degree of limitation was non-compensable.  Board members therefore debated if there was sufficient evidence to warrant application of §4.40 (functional loss) or §4.59 (painful motion).  In this regard, the Board considered the presence of patellar tenderness and crepitus noted by the NARSUM examiner, but an ability to perform a squat in the context of no tenderness or painful motion reported by the C&P examiner.  Ultimately, the Board concluded that application of §4.40 or §4.59 was supported, and therefore separate 10% ratings for each knee were justified.  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 right knee pain condition and 10% for the left knee pain condition, coded 5099-5003.

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.  In the matter of the chronic pain of the right and left knee condition, the Board unanimously recommends that it be rated for two separate unfitting conditions as follows:  chronic right knee pain condition coded 5099-5003 and rated 10%; and chronic left knee pain 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.

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

CONDITION	VASRD CODE	RATING	
Chronic Pain Right Knee 	5099-5003	10%	
Chronic Pain Left Knee	5099-5003	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131202, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX     
President 
Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150011005 (PD201400508)

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,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization 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:

Encl			     XXXXXXXXXXXXXXX
				     Deputy Assistant Secretary of the Army
				         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA