RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00562
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040429

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Automated Logistics Specialist, medically separated by the Informal Physical Evaluation Board (PEB) for “bilateral knee pain,” with a disability rating of 10%.

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.  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 - 20040130	VARD - 20040413	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain, Patellar Chondromalacia	5099-5003	10%	Chondromalacia Patella:  Left Knee	5099-5014	10%	20040210	
			Chondromalacia Patella:  Right Knee	5099-5014	10%	20040210	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  The PEB combined the right and left knee conditions as a single unfitting condition coded analogously to degenerative arthritis (5003) and rated 10%, citing the US Army Physical Disability Agency pain policy.  The approach by the PEB not uncommonly reflected its judgment that there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board also noted that the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements.  The Board’s initial charge in this case was therefore directed at determining if 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.  The evidence for knee conditions is presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Bilateral Knee.  According to service treatment record (STR) and the narrative summary (NARSUM) dated 22 January 2004, the CI had a history of bilateral knee pain since June of 2003 that developed gradually and was increased with weight bearing activities.  He reported “popping” of the knee, but no swelling, locking or “giving way.”  Bilateral knee X-rays showed patellofemoral joint narrowing and spurring of the patella.  Despite treatment with profiles, medications and physical therapy the bilateral knee pain impaired the CI’s performance of the duties of his military occupational specialty and he was given a permanent profile and a Medical Evaluation Board (MEB) was initiated.

The permanent profile dated 27 January 2004 listed bilateral knee pain and the commander’s statement dated 2 December 2003 implicated limitations due to both knee conditions as impairing the CI’s duty performance.

At the MEB exam performed 22 January 2004, 3 months before separation, the CI reported anterior pain in both knees.  The MEB physical exam (reported for both knees) noted tenderness to palpation of the patellofemoral area, without joint line tenderness or effusions.  Goniometric range-of-motion (ROM) was extension-flexion of 0-120 degrees (normal 0-140), with patellar crepitus with motion bilaterally, and no evidence of instability.

At the VA Compensation and Pension (C&P) exam performed 10 February 2004, 3 months before separation, the CI reported bilateral knee pain, aggravated by weight bearing activities and improved by heat, rest and elevation.  The VA exam noted a normal gait without use of braces or a cane or crutch.  There was no swelling or instability of either knee.  Bilateral knee ROM was 0-110 degrees, with painful motion, and there was no additional loss of ROM with repetition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, coded 5099-5003 and cited the US Army Physical Disability Agency pain policy.  The VA rated the right knee and the left knee each 10%, both coded 5099-5014 (analogous to osteomalacia), which is an analogous code for chondromalacia patella.  The Board first considered if both the right and left knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The permanent profile listed the bilateral knee condition; the commander’s statement implicated both knee conditions; and, the NARSUM recommended both knee conditions as causing the CI to fall below retention standards.  The Board concluded that there was not a preponderance of evidence in the STR that overcame the Board’s presumption that the bundled right and left knee conditions are each reasonably considered separately unfitting.  The Board noted that the coding and rating features for both knees are identical and therefore then considered its rating recommendation for both the unfitting knee conditions at the time of separation.

The Board agreed that the evidence in record supports a 10% rating for each knee, coded either according to 5003 rating criteria (as is 5014) for limited motion of a single joint with imaging evidence of arthritis, or coded as 5299-5261 (analogous to limited leg extension), an analogous code for PFS, for painful motion IAW VASRD §4.59 (painful motion).  The Board reviewed to see if a higher rating for either knee was supported, but there was no evidence of joint instability, semilunar cartilage symptoms, ankylosis, or sufficient limitation of ROM for a higher rating of either knee.  The Board thus determined that each knee could be rated 10% and no higher, and chose to code as 5099-5003.  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 condition and the left knee condition.

BOARD FINDINGS:  In the matter of the bilateral knee condition, the Board unanimously recommends an unfitting right knee and an unfitting left knee, each rated 10%, both coded 5099-5003 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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Right Knee Pain	5099-5003	10%	
Left Knee Pain	5099-5003	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140122, 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, AR20160003376 (PD201400562)

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