RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00701
BRANCH OF SERVICE:  Army	BOARD DATE:  20150115
SEPARATION DATE:  20030806

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Logistical Supply) medically separated for chronic bilateral knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The knee condition, characterized as “retropatellar pain syndrome (RPPS)” was 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 due to RPS,” rated 0%, referencing the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Degenerative disc disease lumbar spine, Retropatellar syndrome (Bilateral), Hallux valgus with plantar fasciitis, Bilateral carpal tunnel right wrist, Radiculopathy left lower extremity, Temporomandibular joint function.”

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:

Service IPEB – Dated 20030409	VA - (4 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain due to RPS	5009-5003	0%	RPS Right Knee	5260	10%	20030403	
			RPS Left Knee	5260	10%	20030403	
Other x0	Other x9	20030403	
Combined:  0%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20030725 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The PEB combined the right and left knee conditions under a single Service disability rating, coded analogously to 5003.  Although 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.

In this case, the profile data present for review did not specify which knee caused the duty limitation, just listing “KNEE PAIN (RPPS)” as the medical condition.  There were no other knee related profiles present for review.  Additionally, the commander’s statement only mentioned the CIs’ “…profile prohibits her from doing the duties of a soldier” without specific mention of any condition.  While the narrative summary (NARSUM) noted “CHIEF COMPLAINT: Bilateral knee pain, right greater than left,” the final diagnosis was simply “Retropatellar Pain Syndrome.”  The MEB also simply noted RPPS without specifying right, left or bilateral.  Review of the service treatment records (STR) revealed that early in the CI’s knee related medical history the right knee was initially responsible for her pain; however, shortly thereafter, the left knee was also identified as causing pain.  After deliberations, members agreed therefore that each knee should be conceded as separately unfitting (with the standard of evidence being “reasonably justified”); and, that coding and rating features were logically identical.

Chronic Bilateral Knee Pain.  The CI first complained of knee pain in January 2002.  There was no identifiable injury and the initial X-ray of the right knee was normal.  Over the following months, she was diagnosed and treated for bilateral patellofemoral syndrome, specifically noted as right greater than left.  She had a right knee magnetic resonance imaging study in September 2002 which was normal.  She continued to experience bilateral knee pain despite physical therapy, non-steroidal anti-inflammatory medication and duty restrictions.  Repeat X-rays of both knees in February 2003 were normal.  There was no documentation of instability or swelling.  The NARSUM prepared 5 months prior to separation noted the CI had a 1-year history of bilateral knee pain, right worse than left, was refractory to conservative therapy.  She reported marked limitations in her ability to perform as a supply sergeant secondary to the knee pain.  Additionally, she complained that her activities of daily living were affected; she could not be active in aerobics as she once was, and she had difficulty playing with her child due to her knee pain.  The physical exam findings are summarized in the chart below.  At the VA Compensation and Pension exam performed 4 months prior to separation, the CI reported constant bilateral knee pain affecting her daily functions.

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)	PT ~ 10 Mos. Pre-Sep	MEB ~ 5 Mos. Pre-Sep	VA C&P ~ 4 Mos. Pre-Sep	
	Left	Right	Left	Right	Left	Right	
Flexion (140 Normal)	Full	Full	>90	>90	120	120	
Extension (0 Normal)	Full	Full	0	0	0	0	
Comment	Pos. crepitus; No instability	Pos. crepitus; No instability or effusion; Pos. quadriceps deconditioning	Normal gait; No effusion or instability; Pos. painful motion & crepitus; Pos. Deluca criteria	
§4.71a Rating	10%*	10%*	10%* (PEB 0%)	10%* (PEB 0%)	10%* (VA 10%)	10%* (VA 10%)	
*IAW VASRD §4.59, Painful motion

The Board directed attention to its rating recommendation based on the above evidence.  The PEB applied the analogous code 5099-5003 (degenerative arthritis) and rated it 0% specifically citing the USAPDA pain policy.  The VA coded each knee individually as 5260 (limitation of leg flexion) and rated each knee at 10% based on “pain on movement.”  The STR contained an equal amount of documentation relative to the painful right or left knee with the majority of documentation pertaining to the bilateral knee pain.  As noted above, there were no unilateral distinctions with regards to clinical features, fitness considerations, and the coding and rating features are identical.  There was no degree of ROM limitation, instability, locking or effusion which would achieve a compensable rating under the available knee specific VASRD codes.  The preponderance of exam data met the 10% criteria rating for both the right and left knee separately with application of VASRD principle §4.59 (painful motion).  After due deliberation in consideration of the totality of the evidence, the Board concluded that the right and left knee pain conditions were each reasonably justified as separately unfitting and recommends a disability rating of 10% for the right knee pain condition and 10% for the left 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating bilateral knee pain was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the right knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 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 her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Right Knee Pain	5099-5003	10%	
Left Knee Pain	5099-5003	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 XXXXXXXXXXXXXXX, AR20150011012 (PD201400701)

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			     

CF: 
(  ) DoD PDBR
(  ) DVA