RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-00649	
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20060424		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-7 (Food Service Operations) medically separated for bilateral knee and ankle conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  Her profile allowed for an alternate aerobic event to satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Bilateral knee pain” and “bilateral foot and ankle pain” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic bilateral knee pain” and “chronic bilateral ankle pain” as unfitting, rated 10% and 0% with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The IPEB was silent on adjudicating the CI’s foot pain.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI requests the Board consider all conditions.  Her conditions continue to worsen and negatively impact her daily activities.  Her 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 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 IPEB – Dated 20060117	VA - (3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5003	10%	Left Knee Arthritis	5260-5010	0%*	20060717	
			Right Knee Arthritis	5260-5010	0%*	20060717	
Chronic Bilateral Ankle Pain	5299-5271	0%	Left Ankle Arthritis	5271-5010	0%*	20060717	
			Right Ankle Arthritis	5271-5010	0%*	20060717	
Chronic Bilateral Foot Pain	Medically Unfit (Not addressed by IPEB)	Bilateral Pes Planus And Plantar Fasciitis With Arthritis And Heel Spur Of The Right Foot (Claimed As Condition Of Both Feet With Arthritis)	5010-5276	0%	20060717	
Other MEB/PEB Conditions x 0  (Not in Scope)	Other x 2 	20060717	
Combined Rating:  10%	Combined:  0%	
Derived from VA Rating Decision (VARD) dated 20070125 (most proximate to date of separation [DOS]).   
*VARD dated 20070404 the rating to 10% for arthritis of the bilateral knees and ankles.

ANALYSIS SUMMARY  

Chronic Bilateral Knee Pain:  The CI initially presented with bilateral knee pain in 1994 and was diagnosed with bilateral patellofemoral pain syndrome (PFPS).  She was treated conservatively with physical therapy and pain medications.  Radiographic examination performed on 5 November 1996 demonstrated mild degenerative arthritis.  She underwent two arthroscopic right knee surgeries (August 1999 and July 2003) with transient pain reduction.   At the narrative summary (NARSUM) examination performed 5 months prior to separation the CI reported a patella dislocation in August 2003 and swelling and giving way of knees with walking.  The physical examination was significant for bilateral crepitus (grinding with knee motion), tenderness, positive patellar apprehension test (guarding with movement of the patella).  At a physical therapy evaluation dated 17 November 2005 the therapist noted that the CI was wearing an unloader brace on the right knee.  The therapist documented painful knee motion bilaterally and an antalgic gait.  At the VA Compensation and Pension (C&P) exam performed 3 months after separation, the CI reported bilateral knee  pain, weakness, stiffness, swelling, fatigue, giving way, lack of endurance, locking, fatigability, and dislocation.  On physical examination there was no edema, weakness, tenderness, guarding movements, subluxation or crepitus.  There was no pain with motion.  The goniometric range-of-motion (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 ~ 5 Mo. Pre-Sep	VA C&P ~ 3 Mo. Post-Sep	
	Left	Right	Left	Right	
Flexion (140 Normal)	130	125	140	140	
Extension (0 Normal)	0	0	0	0	
Comment	Painful Motion	Painful motion			
§4.71a Rating	10%	10%	0%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition as a single disability at 10%, coded 5003 (degenerative arthritis).  The VA rated each knee separately at 0%, coded 5260-5010 (leg limitation of flexion-arthritis due to trauma.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings. In this case, both knees were profiled, considered to fail retention standards, and implicated by the NARSUM and in the commander’s statement.  Members agreed that each knee was separately unfitting and that identical coding and ratings are applicable.  The VA examination was most proximate to separation; therefore the Board placed higher probative value on this examination for rating criteria deliberations.  Board members agreed that the radiographic evidence of osteoarthritis in the absence of limitation of motion met criteria for a 10% rating for the bilateral knee condition. The evidence did not support separate ratings for painful motion or a higher rating for leg limitation of motion.  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 bilateral knee condition.  

Chronic Bilateral Ankle Pain:  

A treatment note dated 24 January 2000 documented a healing left talar (an ankle bone that articulates with the leg bones) fracture and ankle sprain.  A 23 March 2004 primary care note documented a diagnosis of right ankle synovitis with physical findings of swelling at the outer right ankle with tendon tenderness to palpation.  The CI was treated with anti-inflammatory medication.  A 29 June 2005 treatment note documented a history of bilateral ankle swelling and pain.  The narrative summary (NARSUM) noted bilateral ankle pain secondary to compensation for knee pain.  On physical examination the right ankle demonstrated swelling at the outer ankle, a positive anterior drawer (increased ankle laxity with forward motion) and tenderness to palpation of the anterior and posterior talofibular ligament (ligaments at the front and back of the outer ankle). The left ankle examination was normal.  At a physical therapy evaluation dated 17 November 2005 the therapist noted decreased right greater than left ankle dorsiflexion and end range right ankle pain in all planes motion.  At the VA Compensation and Pension (C&P) exam performed, the CI reported weakness, stiffness, swelling, giving way, lack of endurance, and locking of her ankles. The CI reported constant ankle pain which increased to 8-9/10 with physical activity.  The pain was relieved by rest and medication.  The ankle examination was normal without evidence of painful motion, tenderness, or abnormal movement. The examiner documented X-ray evidence of right ankle osteoarthritis. X-ray evaluation of the left ankle was normal.  The goniometric range-of-motion (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.

Ankle ROM
(Degrees)	MEB ~ 5 Mos. Pre-Sep	VA C&P ~3 Mos. Post-Sep	
	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	10	5	20	20	
Plantar Flexion (45)	45	45	45	45	
Comment	Normal exam	Painful motion	Normal exam	
§4.71a Rating	0%	10%	0%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the bilateral ankle condition as a single disability rated 0%, coded 5299-5271 (analogous to ankle limitation of motion).  The VA rated each ankle separately at 0%, coded 5271-5010 (ankle limitation of motion-arthritis due to trauma.  The Board considered whether each ankle could be reasonably justified as separately unfitting.  Multiple treatment notes evidenced steroid injections to the right ankle and right greater than left ankle pain.  The NARSUM and VA examinations demonstrated normal left ankle examinations. The NARSUM examination demonstrated abnormal right ankle physical findings.  Board member agreed that the right ankle was reasonably justified as separately unfitting.  Board members determined that there was insufficient performance based evidence to support a conclusion that the functional impairment from the left ankle would have resulted in the CI’s inability to perform her MOS and could not be reasonably justified as separately unfitting.  The Board then considered the rating of the right ankle condition.  The VA examination was most proximate to separation; therefore the Board placed higher probative value on this examination for rating criteria deliberations.  Board members agreed that the radiographic evidence of osteoarthritis and the absence of limitation of motion met criteria for a combined rating of two or more joints (bilateral knees and right ankle) coded 5003.  The evidence most proximate to separation did not support separate ratings for painful motion or a higher rating for ankle limitation of motion.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a single 10% disability rating for the bilateral knee and right ankle conditions IAW VASRD 4.71a rating criteria for 5003 (degenerative arthritis). 

Bilateral Foot Pain:  

The narrative summary (NARSUM) noted a history of bilateral foot pain which begun in 2003.  The CI was diagnosed with bilateral pes planus (flat feet) and plantar fasciitis (inflammation of the lining of the feet).  She was treated with physical therapy and right plantar steroid injections with temporary relief.  At the VA C&P examination, the CI reported constant bilateral foot pain which radiated to the ankles.  The pain was worse in the morning and with prolonged standing, walking and driving.  On physical examination there was moderate pes planus and tenderness to palpation at the metatarsal heads bilaterally (ball of each toe).  The examiner documented radiographic findings of osteoarthritis of the right foot.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB apparently subsumed the bilateral foot condition into the rating of the bilateral ankle condition.  The VA rated the feet under a single rating of 0%, coded 5010-5276 (arthritis due to trauma-acquired pes planus).  The Board first considered whether the bilateral foot conditions could be reasonably justified as separately unfitting.  Although the disability associated with the right foot was greater than the left, bilateral foot pain was profiled and implicated by the NARSUM to fail retention standards.  Members agreed that the disability associated exclusively with right foot could not be isolated from the left; therefore, the evidence supports that each foot could be reasonably justified as separately unfitting.  The Board placed higher probative value on the VA foot examination because the NARSUM examination did not include specific foot examinations.  The VA examination demonstrated subjective reports of pain with use and objective findings of moderate pes planus with tenderness to palpation for a 10% rating, coded 5276 (bilateral or unilateral).  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 bilateral foot 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.  In the matter of the bilateral knee and bilateral ankle conditions, the Board unanimously agreed that each knee and the right ankle were separately unfitting and recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the bilateral foot condition, the Board unanimously agreed that each foot was separately unfitting and recommends a disability rating of 10%, coded 5276 IAW VASRD §4.71a.  In the matter of the left ankle condition, the Board unanimously recommends that it was not separately unfitting.  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 her prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Bilateral knee and right ankle Pain	5003	10%	
Bilateral Foot Pain	5276	10%	
COMBINED w/BLF	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140131, 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 XXXXXXXXXXXXXXXXXXXXXXX, AR20160003070 (PD201400649)

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