RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	   CASE:  PD-2014-00714
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20071113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Unit Supply Specialist) 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 “bilateral chondromalacia patella with osteoarthritis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions (pre-hypertension, bilateral hallux valgus, and laceration to the left index finger) for PEB adjudication.  The Informal PEB (IPEB) adjudicated “bilateral osteoarthritis of knees” as a single unfitting condition, rated 10%.  The remaining conditions were determined to be medically acceptable.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant listed both knees, both feet and left hand finger.  Additionally, he alluded that he has a left leg condition and right hand condition.  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 20070809	VA* - (~5 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Osteoarthritis of Knees	5003	10%	Chondromalacia Patella, Left Knee	5010	10%	20070613	
			Osteoarthritis, Right Knee	5010	10%	20070613	
Bilateral Hallux Valgus	Not Unfitting	Hallux Valgus, Left Foot	5280	0%	20070613	
		Hallux Valgus, Right Foot	5280	0%	20070613	
Laceration, Left Index Finger	Not Unfitting	Laceration to Left Index Finger	5229	10%	20070613	
Other MEB/PEB Conditions x 1 (Not In Scope)	Other x 11 	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20080303 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:    

Bilateral Knee Condition(s).  The service treatment record (STR) corroborates the history in the narrative summary (NARSUM) of the development of bilateral knee pain with running some years prior to separation (the earliest STR complaint dates to 1992).  The working diagnosis was patellofemoral syndrome (non-surgical); and, additionally, bilateral chondromalacia patella (damage to the cartilage under the knee cap) with osteoarthritis was diagnosed by imaging.  It was managed conservatively for several years; but, eventually worsened to chronic pain which was not compatible with the physical demands of soldiering and the MOS.  There are STR entries indicating that the left knee was worse than the right, but persistent bilateral pain is amply documented.  There are several STR entries documenting grossly normal range-of-motion (ROM), with none to the contrary.  There is ample STR documentation (bilateral) of the absence of effusion, stability to stress testing in all planes, and negative signs of cartilage impingement (objective locking).  There are no STR entries contrary to any of these ratable features, or documentation of incapacitating episodes.

A VA Compensation and Pension (C&P) examination was conducted 13 June 2007 (5 months pre-separation) and documented  bilateral knee pain, “left knee is worse;” noting “daily” pain rated 4/10 at rest with exacerbations to 7/10 by “going up or downstairs, heavy lifting ..., squatting, any running,...[and]...prolonged walking more than 200 yards.”  The VA physical examination recorded a normal gait and separate knee examinations; noting patellar tenderness on the left but not the right, and the bilateral absence of effusion, instability, or signs of impingement.  The VA measured ROM was bilateral flexion to 135 degrees (normal 140, minimum compensable 45) and extension 0 degrees (normal); annotating painful motion.

The NARSUM was conducted 20 July 2007 (4 months pre-separation) and was directed at “bilateral knee pain” without differentiating separate acuity or limitations.  It documented “constant” pain rated 4/10 at rest with exacerbations to 8-9/10 by “increasing exercise or running.”  The NARSUM physical examination (no comment regarding gait) recorded separate, but identical, findings for each knee; noting patellar tenderness and crepitus, the absence of effusion, stability to stress testing in all planes, and negative signs of impingement.  The examiner stated, “Motion of both knees was normal.”  Formal ROM measurements for the MEB were performed by physical therapy a day prior to the NARSUM; and, recorded left flexion to 130 degrees, right flexion to 125 degrees, and bilateral extension to 0 degrees; specifying painful motion.  The L3 profile was for “pain both knees.”  The commander’s performance statement did not provide evidence probative to separate fitness implications of either knee.

The Board directed attention to its recommendations based on the above evidence.  The PEB’s bilateral 10% rating analogous to code 5003 (degenerative arthritis) was compliant with VASRD §4.71a criteria under 5003 for two or more major joints.  The VA’s separate 10% determinations under code 5010 (traumatic arthritis, defaulting to criteria of 5003) cited painful motion to achieve the minimum compensable ratings.  There was no compensable ROM impairment, instability, locking, or frequent effusions which would achieve separate ratings higher than 10%.  The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each disability rating.  In this case, although the evidence suggests that the left knee was somewhat more clinically severe than the right; it remains that both knees were considered to fail retention standards; both were implicated by the NARSUM; and, both were profiled.  Since the disability attendant to only the right knee cannot be isolated by the clinical evidence, or extricated from the fitness implications of the bilateral limitations; members agreed that each knee was fairly conceded as separately unfitting.  Separately compensable ratings are thus justified, and painful motion is well supported by the evidence to achieve a 10% rating for each joint.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends separate 10% ratings for each knee; proposing the analogous code 5099-5010 for each.

Contended PEB Conditions (Bilateral Hallux Valgus, Finger Laceration).  The diagnosis of bilateral hallux valgus (bunions) was noted but not elaborated in the NARSUM, and there are no STR entries suggesting any clinical acuity during the MEB.  The pre-separation VA C&P examination dates the onset to 1991, describes mild flares “once a month,” and attributes no limitations to it.  The STR documents a laceration to the left (non-dominant) index finger (radial aspect metacarpal-phalangeal joint) with an orthopedic repair in 1991.  It involved the joint capsule but not tendons.  There is no subsequent STR evidence for any complications or complaints, and the diagnosis was noted but not elaborated in the NARSUM.  The C&P examiner noted inability of lateral excursion in the flexed position which “affects his guitar playing.”  Neither of these conditions was ever profiled; neither was implicated in the commander’s statement; and, both were judged to meet retention standards by the MEB.

The Board directed attention to its recommendations based on the above evidence; and, its main charge with respect to these conditions is an assessment of the fairness of the PEB’s determinations that they were not unfitting.  The Board’s threshold for countering Service fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  All members agreed that there was no performance based evidence suggesting that either of the above conditions significantly interfered with duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determinations for the bilateral foot or finger conditions; thus neither can be recommended for additional disability rating. 

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 condition, the Board unanimously recommends that each joint be rated as separately unfitting at 10%, coded 5099-5010 IAW VASRD §4.71a.  In the matter of the contended PEB conditions (bilateral hallux valgus and left index finger laceration), the Board unanimously recommends no change from the PEB determinations as not 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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chondromalacia Patella and Osteoarthritis, Left Knee 	5099-5010	10%	
Chondromalacia Patella and Osteoarthritis, Right Knee 	5099-5010	10%	
Bilateral Hallux Valgus	Not Unfitting	
Laceration, Left Index Finger 	Not Unfitting	
RATING (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140121, 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 XXXXXXXXXXXXXXXXXXXXXXXX, AR20160002356 (PD201400714)

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